Citations in Illinois
Statistics, citations and compliance trends for long-term care facilities in Illinois.
Statistics for Illinois (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Illinois
A resident with trach/vent dependence, PEG feeding, ESRD, and severe abdominal illness developed vomiting through the trach, abdominal distention, lethargy, and profound hypotension, but full VS were not documented and transfer to the hospital was delayed until after repeated interventions. The facility also missed skin integrity issues for two residents, including a heel wound and a scabbed abrasion linked to shear from lift-sheet/clothing handling, and an LPN was observed giving late morning meds while multiple residents were still highlighted as late on the EMAR.
Pressure ulcer prevention and wound care failures were identified for multiple residents. A resident with immobility and diabetes developed a facility-acquired sacral wound that progressed to an infected stage 4 ulcer requiring hospitalization and debridement, while surveyors observed missed wound vac documentation, stool-contaminated dressings, improper offloading, low air loss mattresses on static mode or incorrect weight settings, missing heel protectors, and a wheelchair resident without a pressure-relieving cushion.
Failure to maintain functional oxygen delivery: Two residents who required continuous O2 via concentrator experienced episodes where the equipment was not delivering oxygen as ordered. One resident reported SOB when the concentrator stopped working and staff temporarily used a portable tank before replacing the unit; another resident reported that the water canister was not attached properly, became unable to breathe, lost consciousness, and was later hospitalized after CPR was initiated. Staff interviews confirmed the concentrators were expected to be checked for proper function and that one RN found no oxygen flow during assessment.
A resident with stroke-related diagnoses and cognitive intact status was transferred to the hospital for weakness, dizziness, pallor, and low K+. After the resident was stable for return, the DON and administrator went to the hospital and, along with the owner and corporate administrator on speaker phone, were reported by the resident and hospital staff to have yelled, been rude and aggressive, and told the resident the facility would not take the resident back because of behaviors and money owed. The resident stated feeling pressured, outnumbered, and insignificant.
Failure to supervise a cognitively impaired resident at high risk for falls led to two unwitnessed falls on the same day. Staff were in other residents’ rooms when the resident fell in the hallway, and later the resident fell again in the dining/common area after attempting to stand from a wheelchair. Documentation was inconsistent about fall precautions and alarms, and one RN stated no VS or neuro checks were done before EMS transport. The resident was sent to the hospital and diagnosed with a spinal compression fracture.
Insufficient CNA Staffing and Delayed Resident Care: Residents and staff reported that CNA coverage was inadequate on evenings, nights, and weekends, leading to delayed call light response and unmet care needs. A resident with impaired mobility and another with CVA-related deficits reported long waits for assistance, while a CNA stated she was the only CNA on a hall overnight and had not been able to check many rooms. The Administrator and CNA Supervisor acknowledged staffing shortages, especially on nights and weekends, and resident council and grievance records also documented concerns about short staffing.
Delayed emergency transfer, missed skin findings, and late medication documentation
Penalty
Summary
The facility failed to assess and document vital signs for a resident who experienced a change in condition and failed to ensure timely emergency treatment. The resident had multiple serious diagnoses, including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, dysphagia with PEG tube feeding, ventilator/tracheostomy dependence, ESRD on dialysis, hypotension, and a history of abdominal perforation and abscess. During the night, the resident was observed vomiting through the tracheostomy with abdominal distention, and the nurse practitioner was notified. Orders were given for Zofran, an enema, residual checks, and removal of the rectal tube. Later, the resident was found to have very low blood pressures, including 63/39 and 76/40, lethargy, and swelling, but the record did not document a full set of vital signs at the time of the change in condition. The resident remained in the facility while staff continued to contact the nurse practitioner and carry out interventions, including midodrine and repeat residual checks. The resident’s blood pressure remained low, dialysis was missed because of hypotension, and the resident was eventually sent to the hospital by private ambulance rather than earlier emergency transfer. EMS documented the resident as lethargic, hypotensive, ventilated, and critically ill, with severe sepsis and septic shock as the primary impression. The resident was admitted to the ICU with septic shock, required Levophed, broad-spectrum antibiotics, and further evaluation for possible infection sources including intra-abdominal, urinary, line-related, and pneumonia. The facility also failed to implement skin prevention interventions and failed to identify skin integrity impairments for two residents. One resident with diabetes, hemiplegia, immobility, and other chronic conditions was observed with bilateral heel boots and dry, scaling skin, and later was found to have wounds on both feet, including a left heel lesion that staff had not previously identified. Another resident with diabetes, immobility, and fecal incontinence reported a scratch on the left lower back/upper buttock area related to staff pulling clothing and a mechanical lift sheet from under the resident. A linear scabbed lesion was observed, and nursing staff initially described it as a healing scratch or stage 2 pressure ulcer before the wound nurse later identified it as an abrasion treated with betadine and a foam dressing. The record showed no prior documentation of skin or wound issues for that resident. The facility also failed to ensure medications were documented at the time of administration and failed to ensure timely medication administration for multiple residents. During observation, an LPN was administering 9:00 a.m. medications at 11:48 a.m., and multiple residents were highlighted as late on the EMAR. When questioned, the LPN stated she was still passing morning medications and then documented one resident’s 9:00 a.m. medications at that time. The report indicates several residents were affected by delayed medication administration and late documentation.
Pressure ulcer prevention and wound care failures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for multiple residents, including residents with severe cognitive impairment, immobility, ventilator dependence, diabetes, and existing pressure injuries. The report states that staff failed to implement preventive interventions to maintain skin integrity, failed to ensure low air loss mattresses were on the correct settings while in use, failed to ensure multiple linen layers were not beneath residents on low air loss mattresses, failed to timely identify skin integrity impairments, failed to follow physician orders, and failed to document or administer prescribed treatments for 10 of 33 residents reviewed for pressure ulcers. For one resident with a facility-acquired sacral pressure ulcer, the record shows the resident was dependent on staff for rolling, had a stage 3 sacral wound identified as in-house acquired, and later developed a stage 4 sacral wound with odor, heavy purulent drainage, necrotic tissue, and signs of infection. The physician documented surgical excisional debridement, noted the wound decline over one week, and recommended transfer to the emergency department. The resident was hospitalized for an infected sacral wound and later records referenced systemic inflammatory response syndrome due to the infected sacral ulcer and a plan for surgical debridement. Survey observations also found the resident lying on a low air loss mattress without the sacral wound offloaded, with a wound vac canister full of blood nearby, and staff observed the wound vac dressing was not adhered and the dressing area was covered with stool. The report also describes multiple other residents whose pressure-relief measures were not maintained as ordered. One resident’s low air loss mattress was observed on static mode and set to an incorrect weight setting; another resident’s mattress was also on static mode; and several residents were observed with heels resting directly on the mattress or with only one heel protector boot available. A resident in a wheelchair was observed without a pressure-relieving cushion despite being at risk for pressure ulcers. For another resident, wound vac treatments were not documented on two scheduled days, and staff statements showed confusion about who was responsible for wound care and when wound vac orders should be carried out. The facility policy stated that residents should receive timely, individualized risk assessments, appropriate preventive interventions, and ongoing monitoring, and that skin changes should be addressed by licensed nurses, but the observations and record review showed these measures were not consistently implemented.
Failure to Maintain Functional Oxygen Delivery
Penalty
Summary
The facility failed to provide continuous oxygen through a functional oxygen concentrator for two residents who required oxygen therapy. One resident with moderate cognitive impairment and one resident with intact cognition both required 3 liters of continuous oxygen via concentrator. Interviews and record review showed that each resident reported a prior incident in which the concentrator was not functioning properly and oxygen was not being delivered as ordered. One resident stated that the concentrator was not working for approximately one-half hour during the night shift, that staff attempted to fix it by changing the water valve, and that he was temporarily placed on a portable tank until the oxygen ran out and he could not breathe. A nurse later obtained a new concentrator. Another resident stated that the water cylinder was not attached appropriately, he became anxious because he could not breathe, and he passed out; he later learned that CPR had been initiated and that he was transported to the hospital by ambulance. Staff interviews confirmed that nurses were responsible for checking that concentrators were functional and that residents were receiving oxygen. One RN stated that when he assessed the first resident, the resident was having difficulty breathing, his oxygen saturation was 87% on room air, and there were no bubbles when he tested the nasal cannula in water, indicating no oxygen flow through the cannula. He temporarily used an oxygen tank and then replaced the entire concentrator. The physician stated that if a resident requiring continuous oxygen is not receiving oxygen, the resident can become hypoxic and may be sent to the hospital. The record review also noted no documentation that the change in condition was monitored for either resident.
Verbal Abuse During Hospital Discharge Discussions
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by facility staff. The resident had diagnoses including frontal lobe and executive function deficit, stroke, atrial fibrillation, cerebrovascular accident, and hemiparesis, and the record also documented the resident as cognitively intact. The resident had been admitted on 01/17/2025 and was transferred to the emergency department on 6/18/2026 for further evaluation and treatment related to possible infection, weakness, dizziness, pallor, and low potassium. After the hospital transfer, the resident stated that facility leaders told the resident the facility would not allow the resident to return because there were no available beds. The resident reported that the administrator and DON came to the hospital, that the administrator, DON, company owner, and corporate administrator were on speaker phone, and that the administrator and DON were verbally abusive, yelled at the resident, and said the resident had behavioral issues, owed the facility a lot of money, and was a bad person. The resident stated feeling pressured, outnumbered, and extremely insignificant, and said the resident never told staff not to return until being told the facility did not want the resident back. Hospital staff corroborated the resident’s account. The hospital social worker stated the facility refused to accept the resident back, that the DON was rude, unpleasant, and harassed the resident in the emergency department waiting room, and that the administrator and DON were aggressive and yelled at the resident during the discussion about returning to the facility. The hospital case manager stated the administrator and DON told the resident about problems the resident had caused for the facility and said the resident could return if the resident paid on the bill. The administrator later stated that staff had to yell because the resident was hard of hearing and acknowledged that the conversation involved reviewing the letter and bullet points about what led to the situation.
Failure to Supervise High-Fall-Risk Resident Resulted in Two Unwitnessed Falls
Penalty
Summary
The facility failed to follow its fall prevention policy and provide adequate supervision for one cognitively impaired resident who was identified as high risk for falls. The resident had an admission fall risk assessment showing high fall risk, and prior hospital PT documentation noted moderate assistance was needed for transfers along with limited safety awareness, impulsivity, cognitive deficit, confusion, decreased endurance, impaired balance, impaired coordination, unsafe gait, and poor safety awareness. On the morning of the incident, the resident had an unwitnessed fall in the hallway while staff were in other residents’ rooms providing care. The resident was confused at baseline, was able to self-propel in a wheelchair, and was assessed with no apparent injuries after the first fall. Documentation stated neurological checks were ordered, but the RN later stated there was no bed/chair alarm in place and that the reference was to a floor mat and call light within reach; the resident fell in the hallway, where no fall precautions were in place at the time. Later the same day, the resident had a second unwitnessed fall in the dining room/common area and was transported by EMS to the hospital after complaining of back pain. Staff reported the resident attempted to stand from the wheelchair and fell to the floor. One RN stated the resident was alert and oriented to person with baseline confusion and that no vital signs or neurological checks were performed before EMS transport, while another note documented the resident was alert and responsive with altered mental status at baseline, no visible head injury, and back pain. The resident was admitted to the hospital with altered mental status, pneumonia, and a spinal compression fracture. The facility’s fall documentation also contained inconsistencies, including a note stating a bed/chair alarm was in place and functioning despite later staff statements that no such alarm was used.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs in a timely manner and failed to have enough CNA coverage on evenings, nights, and weekends. The report states the facility had 108 residents and could not provide a staffing policy. Interviews with the Administrator and CNA Supervisor confirmed that nights and weekends were the hardest shifts to fill, that staff shortages were common, and that administrative staff were being used to help cover evening hours when CNA shifts were not fully staffed due to call-ins or no-shows. The CNA Supervisor also stated that optimal staffing on the 200 hall would be two CNAs on all shifts because many residents required two-person assistance with mechanical lifts. Several residents described delayed responses to call lights and assistance needs. One resident with diagnoses including acute respiratory failure, diabetes mellitus, anemia, anxiety disorder, and cognitive communication deficit stated the call light system was not working and that she had been given a whistle to use instead; she reported prolonged waits for staff response, especially after dinner and overnight, and said she had had incontinence episodes while waiting. Another resident with cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit stated she waited longer in the evening and overnight when using the call light, and that weekends seemed to have less staff available. A family member present during that interview stated staff worked hard but did not have enough help, especially on second shift and weekends. A third resident with anemia, muscle weakness, and need for assistance with personal care stated her call light system did not work and she had been given a dinner bell to use when needing assistance. She reported waiting 30 minutes or more for help with her incontinence brief during evening and overnight hours. A CNA working the night shift stated she was the only CNA assigned to the 200 hall at that time, that only 5 CNAs total were working nights including the supervisor, and that she had only checked 4 rooms since arriving before 2:00 AM, with 8 rooms or 11 residents still not checked on her hall. Resident council minutes also documented concerns that there were not enough CNAs on weekends, and a grievance form documented a resident complaint about not receiving a shower due to short staffing.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in Illinois — free
You're all set
Compliance trends in Illinois
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
