Based on observation, interview, and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented policies for wound care, medication administration, treatment administration, quality assurance measures, and basic activities of daily resident care. These failures resulted in a facility-wide lack of supervision and care leading to residents experiencing worsening pressure ulcers, severe pain, a lack of resident care for gastrostomy tubes and pressure ulcer treatments with subsequent infections requiring hospitalization, untimely assistance with incontinent care and showers resulting in residents being left in soiled conditions for extended periods, missed medication administrations with significant medication errors, and not providing a… …
F835 citations in Illinois
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F835 less often than its own record predicts
0.46 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F835 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 observation, interview and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented their policies for protecting resident's dignity, be free of involuntary seclusion and restraints, accurately assessed residents and provided quality of care based on those assessments, services were provided to meet professional standards, ADL (Activities of Daily Living) cares were provided for dependent residents, medications were safely administered, infection prevention measures were implemented and appropriately utilized, staff were qualified and competent and maintained a safe/ clean/comfortable environment. …
Based on interview and record review the facility failed to administer the facility by failing to ensure a qualified individual was hired as the social service director. This has the potential to affect all 182 residents in the facility.Findings include:On 7/24/26 at 9:12 AM, V1 Administrator stated the requirement for the social services director was to have a minimum of a bachelor's degree and 1 year of experience in social services. V1 stated V4 Social Service Director - SSD is in school for her bachelor's degree; it is not completed. V1 stated the facility has an average daily census between 175-180 residents. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.19% | 0.67× |
| 2024 | 0.22% | 0.68× |
| 2025 | 0.13% | 0.46× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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