Based on observation, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as a part of the regular maintenance program to identify areas of possible entrapment for 3 of 3 residents (R1, R2, and R3) reviewed for side rails. The facility did not provide any documentation of inspection or entrapment assessments.Findings include: Recommendations for Health Care Providers Using Adult portable Bed Rails dated 2/27/2023 retrieved on 4/13/26 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/hospital-beds indicated, when evaluating the safe use of a hospital bed, component or accessory, manufacturers and caregivers should recognize that the risk for entrapment may increase if a hospital bed system… …
F909 citations in Minnesota
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
Minnesota cites F909 more often than its own record predicts
2.50 times the share F909 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F909 findings written in Minnesota, 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.
Based on observation, interview, and document review, the facility failed to develop and implement a preventative, regular maintenance program of resident' beds and side rails to ensure safety and reduce the risk of complication (i.e., bed malfunction, entrapment) for 3 of 3 residents (R122, R45, R222) reviewed who used side rails on their bed. However, the lack of a program had potential to affect all 75 residents residing at either campus. Findings include: R122's admission Minimum Data Set (MDS), dated [DATE], identified R122 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS included a section labeled, Section P - Restraints, which marked R122 as not using a bed rail with dictation, 0 = Not Used. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.06% | 0.46× |
| 2024 | 0.16% | 1.33× |
| 2025 | 0.27% | 2.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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