F909 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F909 more often than its own record predicts
Versus expected share1.22×
1.22 times the share F909 takes of citations nationally.
Share of California citations0.13%
Of every deficiency written in California in 2025, this is the portion that was F909.
California0.13%
National0.11%
Share of all citations that were F909.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F909 findings written in California, 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.
J · Immediate jeopardy, isolatedSeptember 9, 2021
Based on observation, interview and record review the facility failed to ensure a resident's right bed siderail was regularly maintained and checked if the bed siderail was safe for use for one of three sampled residents (Resident 1). Resident 1's right bed siderail was broken and would not stay locked in an upright position.
This deficient practice resulted to the Resident 1's right bed siderail gave way, and Resident 1 fell from her bed on to the floor, on 5/5/21. Resident 1 sustained a bump on her head initially, on 5/5/21, and on 5/20/21, Resident 1 was transferred to the hospital due to a fracture (broken bone) of her right hip. …
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the resident entrapment assessment was completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of the side rails for one of one final sampled residents (Resident 37) reviewed for side rails. * The facility failed to complete the Zone 4 (gap between the headboard and the halo ring) entrapment measurement for Resident 37's halo safety ring. This failure resulted in an incomplete entrapment assessment and created the potential for resident harm, including entrapment, serious injury, or death. …
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