Facility failures resulted in two deficient practices.A. Based on observation, interview, and record review, the facility failed to provide adequate heating to the St. [NAME]/100 Hallway and rooms and failed to follow facility emergency protocol. These failures have caused R1 to have increased pain from muscle spasms due to being tense from the cold. These failures have the potential to affect all 31 residents residing on St. [NAME] wing, R1, and R3-R32. This failure resulted in an Immediate Jeopardy.B. Based on observation, interview, and record review the facility failed to provide adequate hot water to the entire building. This has the potential to affect all 59 residents residing in the facility. Findings include:A. The Immediate Jeopardy began on 1/12/26 around 8:00 AM. …
F921 citations in Illinois
Safe, clean, comfortable environment · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F921 more often than its own record predicts
1.15 times the share F921 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F921 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 ensure a light fixture was in safe operating order. This failure resulted in the light fixture falling from the ceiling, landing on the resident while in bed, and R1 sustaining a second degree burn. This applies to 1 of 3 residents (R1) reviewed for safe physical environment in the sample of 3.The findings include:R1' s electronic face sheet documents R1 has diagnoses that include peripheral vascular diseases, left leg amputee, and hypertension.R1's facility assessment, dated 10/3/25, show R1 has no cognitive impairment.R1's Emergency Department (ED note), dated 10/6/25, documents, Patient presented from facility burned to right upper arm. …
Based on observation, interview, and record review, the facility failed to maintain the facility in a clean, sanitary, functional, safe, and comfortable condition. This failure has the potential to affect all 92 residents residing in the facility. Findings Include:The facility's Maintenance Director Job Description, revised 5/26/26, documents the Maintenance Director is responsible for repairing facility and resident property as necessary; coordinating with outside vendors when repairs could not be completed internally; ensuring outside vendor services were properly completed and supervised; inspecting storage rooms, workrooms, utility and janitorial closets for upkeep and supply control; participating in facility inspections; developing plans of correction for maintenance deficiencies;… …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.87% | 1.01× |
| 2024 | 0.69% | 0.86× |
| 2025 | 0.97% | 1.15× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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