F909 in Michigan. Pick another state for the same tag.
Against expectation — 2025
Michigan cites F909 less often than its own record predicts
Versus expected share0.73×
0.73 times the national share — cited less often here than elsewhere.
Share of Michigan citations0.08%
Of every deficiency written in Michigan in 2025, this is the portion that was F909.
Michigan0.08%
National0.11%
Share of all citations that were F909.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Michigan surveyors wrote
F909 findings written in Michigan, 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.
J · Immediate jeopardy, isolatedOctober 24, 2018
Based on observation, interview, and record review, the facility failed to perform regular bed frame, mattress, and bed rail inspection and maintenance, resulting in the risk of serious harm and death for one Resident (#57), out of one resident reviewed for entrapment. This deficient practice resulted in Resident #57's entrapment on [DATE] and [DATE], and continued risk of injury and entrapment from potential bed frame, rail, and mattress incompatibility, and failure to follow manufacturer instructions. The facility failed to take actions to prevent further such incidents, which had the potential to affect all 73 facility residents, resulting in immediate jeopardy.
The immediate jeopardy began on [DATE] at 11:00 p.m. …
This citation pertains to intake 2563197. Based on observation, interview and record review, the facility failed to perform routine inspections and maintenance to ensure safety of resident beds for 1 of 1 resident (R108) reviewed for bed safety, resulting in a life-altering injury for R108 and potential for further injury for 9 additional residents who had foot-board brackets on their beds with no foot board.Findings include: According to the Minimum Data Set (MDS) dated [DATE], R108 had a BIMS (Brief Interview Mental Status) of 9/15, indicating the resident was cognitively impaired. Diagnoses that included cognitive communication deficit and history of falling. …
D · No harm, potential for more than minimal, isolatedDecember 15, 2025
Based on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#7) of one resident reviewed for bed safety. Findings Included: Resident #7 (R7):Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. …
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