Based on observations, interviews, and facility policy review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for one of 26residents (Resident (R) 63) whose beds were observed for bed rail safety out of a total sample of 26. The facility failed to ensure R63's bed rails were identified and repaired timely when broken, which had the potential to cause injury to the resident. Findings include: Review of the facility's policy titled, Side Rail Policy, last reviewed 07/23/24, revealed, The purpose of these guidelines is to ensure the safe use of side rails . …
F909 citations in New Jersey
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 — 2024
New Jersey cites F909 less often than its own record predicts
0.85 times the national share — cited less often here than elsewhere.
Of every deficiency written in New Jersey in 2024, 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 New Jersey surveyors wrote
F909 findings written in New Jersey, 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 New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 1.73× |
| 2024 | 0.10% | 0.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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