F909 in Missouri. Pick another state for the same tag.
Against expectation — 2025
Missouri cites F909 more often than its own record predicts
Versus expected share4.14×
4.14 times the share F909 takes of citations nationally.
Share of Missouri citations0.45%
Of every deficiency written in Missouri in 2025, this is the portion that was F909.
Missouri0.45%
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 Missouri surveyors wrote
F909 findings written in Missouri, 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.
D · No harm, potential for more than minimal, isolatedJune 18, 2026
Based on observation, interview, and record review, the facility failed to conduct regular inspections of all bed frames, mattresses, side rails and trapeze (an overhead assistive device with a suspended triangular handle) as part of a regular maintenance program for seven residents (Residents #8, #16, #84, #155, #162, #172, and #173) out of 33 sampled residents. The facility's census was 169.
Review of the facility's policy, Bed Rails, revised 06/20, showed:
- Before installing a bed rail, the facility must assess the resident for the risk of entrapment from bed rails and ensure the bed's dimensions are appropriate for the resident's size and weight. …
C · No harm, potential for minimal, widespreadDecember 8, 2017
Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for two out of two residents with side rails (Residents #3, and #5) to ensure the environment remained safe and free of accident hazards. The facility census was 26.
1. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] shows 413 people died as a result of entrapment events in the United States. Further review reveals those among the most vulnerable for these entrapment type events are elderly patients and residents especially those who are frail, confused, restless, or who have uncontrolled body movement. …
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