Based on clinical record review, observation, and interviews for 1 of 5 sampled residents (Resident #130) who was reviewed for falls, the facility failed to ensure the resident's bed rails were secure. The findings included: Resident #130's diagnoses included fracture of unspecified part of left femur, displaced fracture of greater trochanter of left femur, and fracture of nasal bones. The Resident Care Plan dated 7/5/23 identified unsteadiness with ambulation, a risk for falls related to unsteady, poor safety awareness, taking medications with effects of sedation and vision problem. Interventions directed to maintain current safety protocols, bed alarm, and to encourage use of roller walker. …
F909 citations in Connecticut
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 — 2023
Connecticut cites F909 more often than its own record predicts
1.77 times the share F909 takes of citations nationally.
Of every deficiency written in Connecticut in 2023, 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 Connecticut surveyors wrote
F909 findings written in Connecticut, 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.
What else Connecticut surveyors cite →
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