Based on observation, interview, and record review, the facility failed to store a Schedule II Controlled medication (Morphine Sulfate) in a locked location by leaving the medication on top of the medication cart in plain view, unsupervised, and readily accessible to wandering residents on a dementia care unit. This failure resulted in facility staff observing R1 at the medication cart with the bottle of Morphine placed to R1's lips, when staff removed the bottle, no medication remained in the bottle and then staff later observed R1 unresponsive with a decreased respiration rate followed by staff administering Narcan (an emergency medication that rapidly reverses life-threatening opioid overdoses) and sending R1 to the hospital emergency room for evaluation and treatment. …
F761 citations in Illinois
Drug labeling and storage · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F761 less often than its own record predicts
0.84 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F761.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F761 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 safeguard and properly store a medication that led to a confused resident ingesting that medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for medication storage. Findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred on 12/17/2023 between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/23 at 1:13 AM. Soon after delivery, V19 left the medications on top of V20's (RN) medication cart which was inside a locked unit without informing V20 of the delivery. …
Based on observation, interview, and record review the facility failed to ensure that individual medication for one resident (R2) was locked safely in the medication cart when not in view of the licensed nurse, failed to lock nursing supply room that contained medications, and failed to ensure one resident (R2) medication was not left at bedside. These failures affected R2 reviewed for medication administration and storage and has the potential to affect all 127-residents residing at the facility.Findings include: 1.) On 08/24/26 at 10:51am, V2 (Director of Nursing/DON) stated that OTC (Over the counter medications) medications are kept in the basement in the nursing supply room. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 2.90% | 0.91× |
| 2024 | 2.75% | 0.90× |
| 2025 | 2.72% | 0.84× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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