F909 in North Carolina. Pick another state for the same tag.
No F909 citations were recorded in North Carolina for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What North Carolina surveyors wrote
F909 findings written in North Carolina, 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.
G · Actual harm, isolatedJuly 9, 2026
Based on record review and staff interviews, the facility failed to ensure that a circular bed rail was maintained in safe working condition. As a result, the rail did not remain secure, and the resident fell from the bed during care sustaining a fractured femur (the long thigh bone). This deficient practice affected 1 of 1 resident (Resident #1) reviewed for bed rails. Findings included:A review of the facility's Bed and Bedrail Safety Inspection Policy dated 11/2025 indicated that maintenance personnel and clinical staff were responsible for bed safety. The policy indicated that all beds must be inspected regularly to ensure compliance with safety standards. …
D · No harm, potential for more than minimal, isolatedJune 27, 2019
Based on record review, observation, and staff interview, the facility failed to evaluate the bed frame to mattress size for compatibility and to regularly inspect bedrails, mattresses and bedframes (Resident #8) for 1 of 1 reviewed for physical environment.
Findings included:
Resident #8 was admitted on to the facility on [DATE] with [DIAGNOSES REDACTED].
A review of Resident #8's Device Evaluation form (side rails) dated 5/10/18 revealed reason for evaluation was quarterly. Interventions attempted were blank.
A review of Resident #8's Device Evaluation form (side rails) dated 8/2/18 revealed reason for evaluation was quarterly, the resident was alert with short and long term memory deficit, was cooperative, received antipsychotic, anti-anxiety, diuretic, and anti-hypertensive. …
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