Based on interview and record review the facility failed to accurately transcribe an opioid analgesic medication order and failed to ensure nursing staff questioned and verified a large dose of a high-risk medication (Morphine 500 mg) before administration. This failure resulted in R5 experiencing drowsiness, respiratory depression, and memory loss. R5 was treated with Narcan (opioid antagonist) and later sent to the emergency room. These failures affected one of three residents (R5) reviewed for Pharmaceutical Services on the sample list of ten. The Immediate Jeopardy began on 3/10/26 when R5 was given an overdose of Morphine Sulfate (500 milligrams). V1 Administrator was notified of the Immediate Jeopardy on 3/31/26 at 2:50 PM. …
F760 citations in Illinois
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F760 more often than its own record predicts
1.17 times the share F760 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F760 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 ensure residents were free from significant medication errors for 1 (R1) of 3 residents reviewed for medication administration in the sample of 8. This failure resulted in R1 receiving an intermittent access (INT) needle placed in her left hand, after unsuccessful attempt to right forearm, two doses of Meropenem 500 MG (milligrams) IV (intravenous), and sent to the local emergency room for treatment of nausea.This past non-compliance occurred between 7/27/2026 and 7/28/2026. …
Based on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 3 residents (R1) reviewed for medication errors.Findings include:R1's admission Record documents an admission date of 11/27/2013. admission records include diagnoses of Hypertensive Heart Disease with heart failure, Crohn's Disease of both small and large intestines without complications, Muscle Wasting and Atrophy, Lack of Coordination, Dysphagia oral phase, Abnormal Posture, Hyperesthesia, Atherosclerotic Heart Disease, Hyperlipidemia, Anxiety, Sever Intellectual Disabilities, Osteoporosis, Major Depressive Disorder, and Physical Debility. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 1.30% | 1.18× |
| 2024 | 1.44% | 1.24× |
| 2025 | 1.53% | 1.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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