Based on interview and record review, the facility failed to obtain physician ordered laboratory testing in 1 of 3 residents (R2), reviewed for medication monitoring in the sample of 9. This failure resulted in R2 being admitted to the hospital on 5/8/25, where he remains. R2 was diagnosed in the hospital with Supratherapeutic INR (Initial Normalized Ratio) with a level greater than 10 (target range is between 2-3) and had to receive medication to reverse the effects from the anticoagulant, Warfarin, that R2 was receiving in the facility for a diagnosis of Pulmonary Embolism. This failure resulted in an immediate jeopardy when the facility failed to obtain laboratory testing to monitor R2's anticoagulant levels to ensure a therapeutic level was obtained. …
F757 citations in Illinois
Unnecessary drugs · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F757 less often than its own record predicts
0.39 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F757.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F757 findings written in Illinois, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to establish a correct indication and frequency in the use of antipsychotic medication (Seroquel); failed to obtain complete consent for use of antipsychotic medication; and failed to adequately monitor adverse reactions, evaluate effectiveness and relevance of antipsychotic medication on a resident with Alzheimer's disease. This failure resulted in R1 hanging himself with a cellphone cord and required emergent transfer to the hospital.Findings include:R1 is a [AGE] year-old, male, admitted in the facility on 02/14/26 with the following diagnoses: Alzheimer's Disease, Unspecified; Unspecified Dementia, Moderate, with other Behavioral Disturbance; Memory Deficit Following Cerebral Infarction and Restlessness and Agitation.R1's MDS… …
Based on interview and record review, the facility failed to ensure a resident was free from unnecessary medications. This applies to 1 of 2 residents (R1) reviewed for antibiotic use in the sample of 25. The findings include:The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including sepsis, pneumonia, and dehydration. R1's Order Audit Report dated May 6, 2026, showed an order dated April 16, 2026, for Ciprofloxacin oral tablet 250 mg (milligrams), give one tablet by mouth two times a day for UTI (Urinary Tract Infection) for five days. The documentation showed R1 completed her order of ciprofloxacin for five days. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 0.24× |
| 2024 | 0.14% | 0.20× |
| 2025 | 0.31% | 0.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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