Based on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure bed rails were adequately secured to the bed. This affected one (#23) of one resident reviewed for bed rails. The facility census was 151. Findings include: Review of the medical record of Resident #23 revealed an admission date of 08/20/25. Diagnoses included heart failure, Type II Diabetes Mellitus, and ischemic cardiomyopathy. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for bed mobility. Review of physician orders revealed an order dated 08/20/25 for 1/4 side rails on both sides of the bed. …
F909 citations in Ohio
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
Ohio cites F909 less often than its own record predicts
0.28 times the national share — cited less often here than elsewhere.
Of every deficiency written in Ohio 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 Ohio surveyors wrote
F909 findings written in Ohio, 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 Ohio citations | vs expected |
|---|---|---|
| 2024 | 0.05% | 0.41× |
| 2025 | 0.03% | 0.28× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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