Based on observation, record review, and interview, the facility failed to complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing two Residents (#2 and #8), out of a sample of 12 residents, who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Findings include:Review of the facility's policy titled Proper Use of Siderails, revised 2/1/2018, indicated but was not limited to the following:- Manufacturer instructions for the operation of side rails will be adhered to.- When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of… …
F909 citations in Massachusetts
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
Massachusetts cites F909 more often than its own record predicts
3.90 times the share F909 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F909 findings written in Massachusetts, 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 Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.30% | 2.14× |
| 2024 | 0.24% | 2.06× |
| 2025 | 0.42% | 3.90× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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