Based on observation, interview, and record review the facility failed to ensure residents'' rooms were located at or above ground level which applies to 24 of 62 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) reviewed for facility enviorment in a sample of 62.The findings include: On 8/5/25 at 10:00 AM 24 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) were observed on the lower-level floor in rooms located below ground level.The facility's memory care roster (100 unit) showed a census of 24 residents.On 8/4/25 at 11:00 AM, V1 Administrator stated the memory care unit (100 unit) rooms are below the level of the ground. …
F916 citations in Illinois
Environmental Deficiencies
Ensure each resident has a room at or above ground level.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F916 more often than its own record predicts
16.21 times the share F916 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F916.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F916 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 observations and interviews, the facility failed to have the floor of the resident rooms at the garden or above the ground level. This applies to 36 of the 36 (R1, R4, R6, R7, R11, R14, R15, R16, R18, R26, R29, R31, R34, R36, R39, R42, R43, R45, R46, R47, R52, R53, R66, R67, R68, R76, R87, R91, R98, R99, R101, R102, R103, R104, R108) residents reviewed for physical environment. The findings include: Residents rooms B1, B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, B12, B13, and B14 are below the below the garden or ground level. On 10/31/2024 AT 11:00 AM, V1 (Administrator) said since its inception, the facility has had the same structure, and every year, the facility receives the deficiency during the annual survey.
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.03% | 8.72× |
| 2024 | 0.03% | 10.61× |
| 2025 | 0.03% | 16.21× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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