Based on observation, record review and interview, it was determined that for one (R94) out of four residents reviewed for accidents, the facility failed to ensure R94's bilateral bed rails were being included in a routine maintenance safety check. Findings include: Review 94's clinical record revealed: 1/5/26 2:11 PM - Observation of bilateral bed rails positioned up on R94's bed. 1/9/26 9:49 AM - Observation of R94 in bed revealed bilateral bed rails positioned up and no gap. R94 confirmed that he used them during therapy sessions. 1/9/26 10:13 AM - During an interview, E30 (Maintenance Director) was asked if there are routine maintenance/safety inspections of bed rails being performed in the facility. He stated no, but he would start doing this. …
F909 citations in Delaware
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
Delaware cites F909 more often than its own record predicts
3.91 times the share F909 takes of citations nationally.
Of every deficiency written in Delaware 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 Delaware surveyors wrote
F909 findings written in Delaware, 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 Delaware surveyors cite →
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