Based on interview and record review, the facility failed to provide and properly maintain essential lifesaving medical equipment during a respiratory medical emergency for R1. R1 did not have the benefit of essential lifesaving equipment including an oral suctioning device and mechanical ventilation device for responding medical staff to use during a respiratory medical crisis. As a result, R1 was not provided airway management and rescue breathing. R1 subsequently died of Acute Cardiopulmonary Arrest. R1 is one of three residents (R1) reviewed for basic life support. This failure has the potential to affect ten (10) additional residents (R4-R13) who have chosen to be a Full Code. …
F908 citations in Illinois
Equipment in safe condition · Environmental Deficiencies
Keep all essential equipment working safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F908 more often than its own record predicts
1.02 times the share F908 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F908.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F908 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 low air loss mattress was in proper working order for 1 of 3 residents (R2) reviewed for essential equipment, safe operating condition in a sample of 10. This resulted in R2 being in extreme pain due to R2 having multiple pressure ulcers/injuries, the mattress not staying properly inflated, and R2 laying on a hard metal bed frame. Findings Include: R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting.R2's Face Sheet, print date of 12/04/25, documented R2 has diagnoses including pressure ulcer of right… …
Based on observation and interview, the facility failed to ensure the shower room was maintained in a safe, functional and operating condition. This applies to all residents residing in the facility reviewed for physical environment in the sample of 9. The findings include: The census report dated 8/24/26 shows 49 residents residing in the facility. On 8/25/26 at 9:35 AM, a tour of the facility was conducted with V8 (Maintenance Director). The shower room on the north hall had several wet bath blankets placed outside the doorway leading into the hallway. Black debris and buildup were present throughout the shower room floor. The shower room was dirty, unmaintained and contained fecal matter on the floor. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.32% | 0.69× |
| 2024 | 0.26% | 0.58× |
| 2025 | 0.46% | 1.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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