Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for one (1) of fourteen (14) sampled residents (Resident #42). Observation of Resident #42's bed on 12/07/2023, revealed there was a large gap between the side rails and bed mattress. The findings include: Review of the facility policy titled, Bed/Side Rail Use, dated 04/2018 and reviewed on 01/2022, revealed the facility would attempt to use appropriate alternatives prior to installing a bed rail or side rail. …
F909 citations in Kentucky
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
Kentucky cites F909 more often than its own record predicts
4.36 times the share F909 takes of citations nationally.
Of every deficiency written in Kentucky 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 Kentucky surveyors wrote
F909 findings written in Kentucky, 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 Kentucky surveyors cite →
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