Based on observation and interview the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. The deficient practice puts all residents at risk for possible entrapment if they have bed rails and they are not inspected and maintained according to manufacturer's recommendations and requirements.Findings Include:1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed. 2) On 02/25/2026 at 9:05 AM R38 was observed lying in her bed with bilateral upper quarter bed rails which were up in use. …
F909 citations in Hawaii
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 Hawaii 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 Hawaii surveyors wrote
F909 findings written in Hawaii, 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 Hawaii surveyors cite →
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