Based on record review and interviews it was determined the facility staff failed to conduct regular inspections of resident beds. This has the potential to affect all residents in the facility. The findings include:Review of anonymous complaint #2963504 on 4/28/26 at 1:00 PM revealed a concern regarding bed inspections. The surveyor was informed by the Administrator that the Director of Maintenance was not in the facility at that time. The facility's bed inspection logs were requested for review. On 4/29/26 at 11:29 AM, after several additional requests for the logs, the Administrator was asked if routine inspection of the beds was actually conducted. He indicated yes but we haven't kept very good records. …
F909 citations in Maryland
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
Maryland cites F909 more often than its own record predicts
3.02 times the share F909 takes of citations nationally.
Of every deficiency written in Maryland 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 Maryland surveyors wrote
F909 findings written in Maryland, 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.
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.60× |
| 2024 | 0.32% | 2.70× |
| 2025 | 0.33% | 3.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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