F805 in Illinois. Pick another state for the same tag.
Against expectation — 2025
Illinois cites F805 more often than its own record predicts
Versus expected share1.62×
1.62 times the share F805 takes of citations nationally.
Share of Illinois citations0.49%
Of every deficiency written in Illinois in 2025, this is the portion that was F805.
Illinois0.49%
National0.31%
Share of all citations that were F805.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F805 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.
J · Immediate jeopardy, isolatedMay 22, 2026
Based on interview and record review the facility failed to provide a resident with the Physician prescribed diet, failed to have a policy in place regarding changes in dietary orders, and failed to implement a physician diet order change. This failure resulted in R1 choking on her food and expiring at the hospital. This applied to one of three residents (R1) reviewed for diets in the sample of three.The Immediate Jeopardy began on 5/17/26 when R1 received physician orders for a downgrade in diet to pureed and the next morning was served a mechanical soft diet rather than the Physician prescribed puree diet. R1 choked and expired at the hospital. V1 (Administrator) was notified of the Immediate Jeopardy on 5/22/26 at 9:58 AM. …
Based on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency. This failure resulted in R10 requiring emergency care after choking on pizza. This applies to 1of 19 (R10) residents reviewed for mechanically altered diets in the sample of 19.
The findings include:
The facility face sheet for R10 shows diagnosis to include chronic obstructive pulmonary disease, dysphagia and history of cerebral infarction. The facility assessment dated [DATE] shows R10 to be cognitively intact and requires limited assistance with eating. …
E · No harm, potential for more than minimal, patternJuly 8, 2026
Based on observation, interview, and record review the facility failed to ensure the pureed macaroni and cheese was a smooth consistency, not requiring chewing. This applies to 4 of 4 residents (R30, R17, R38, R44) reviewed for puree diets in the sample of 23. The findings include: Facility provided Thicken Liquids/Fluid Restrictions/Puree form dated 7/1/26 shows R30, R17, R38, and R44 receive Puree Diets. On 7/6/26 at 11:11 AM, V6 (Food Service Director) finished pureeing the macaroni and cheese. V6 tested the consistency of the puree macaroni and cheese and was chewing while V6 said, nobody is going to choke on that. The puree macaroni and cheese appeared chunky as V6 scooped it into a steam table pan. …
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