Based on observation, interview, and record review the facility failed to ensure that the bed frame is locked to the size of the mattress for the safety of one resident (R1) reviewed for injury. As a result, R1's left lower leg made contact with the loose bed frame during transfer into bed causing a laceration. R1 was sent to the hospital and the laceration was repaired with 18 sutures. This has the potential to affect all 70 residents residing in the facility. Findings include: R1's medical record Admission Record showed that R1 was originally admitted to the facility on [DATE] and latest admitted was 08/26/24 with diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare… …
F909 citations in Illinois
Environmental Deficiencies
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F909 less often than its own record predicts
0.55 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois in 2025, this is the portion that was F909.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F909 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 maintain environmental equipment safety, comfortability and appearance for a torn/ripped bed mattress that created unsafe gaps for one resident (R10) reviewed for environment in a sample of 14.Findings include:On 6/18/26 at 8:11 am, R10 was sitting in a wheelchair in R10's room and R10's bed was unmade (no sheets/blankets/bedspread). An exposed blue mattress had a moderate amount of brown/tan punctures on the outer layer that exposed the internal mattress materials and exposed dips/lumps were noted on the sleeping surface. R10 stated, Oh, they know about it, I have been telling them about this mattress for over a year. It looks terrible and is very uncomfortable. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.80× |
| 2024 | 0.06% | 0.49× |
| 2025 | 0.06% | 0.55× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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