Based on observation, interview, record review, and policy review, the facility failed to implement a regular maintenance program to ensure bed systems, including bed rails, mattresses, and frames, were inspected for safety and potential entrapment hazards. The facility did not conduct routine assessments of mattress fit or measure potential entrapment zones in accordance with Food and Drug Administration (FDA) guidance. This had the potential to affect 14 of 19 sampled residents (Resident (R) R2, R3, R5, R8, R11, R12, R4, R9, R13, R22, R23, R25, R26 and R27) who used bed rails and had the potential to result in injury related to bed entrapment or bed system malfunction. …
F909 citations in Guam
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.
No F909 citations were recorded in Guam for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Guam surveyors wrote
F909 findings written in Guam, 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 Guam surveyors cite →
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