Based on interview and record review, the facility failed to follow their physician notification of laboratory/radiology/diagnostic results policy by not notifying the physician/nurse practitioner of a sacral wound culture results indicating high amount of bacteria (greater than 100,000 pseudomonas aeruginosa) for one resident (R2) who had a stage three sacral pressure ulcer. This affected one of three (R2) residents reviewed for notification of an abnormal lab result. This failure resulted in R1 not receiving any antibiotic treatments and being hospitalized two weeks later with a diagnosis of sacral osteomyelitis. …
F777 citations in Illinois
Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F777 more often than its own record predicts
1.20 times the share F777 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F777.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F777 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 record review and interview the facility failed to obtain a physician ordered MRI (Magnetic Resonance Imaging) for one of seven residents (R1) reviewed for pain in the sample of seven.Findings include:The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results dated 12/2025 documents, Purpose: To ensure physician ordered diagnostic tests are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 2.06× |
| 2024 | 0.05% | 1.62× |
| 2025 | 0.03% | 1.20× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction