Based on observation, interview, and record review the facility did not ensure proper inspection of resident's beds for 2 (R110 & R59) of 5 beds. *A gap of approximately five inches was observed between R110's air mattress and foot board on 6/1/256 & 6/2/26. *On 4/17/26, staff reported R59's bed suddenly lifted on the window side causing R59 to fall on the floor. Post-incident inspections identified a broken clip securing the air mattress strap to R59's bed frame. There is no evidence that R59's bed was inspected after the air mattress was placed. …
F909 citations in Wisconsin
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
Wisconsin cites F909 less often than its own record predicts
0.67 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F909 findings written in Wisconsin, 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.
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.79× |
| 2024 | 0.04% | 0.30× |
| 2025 | 0.07% | 0.67× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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