Based on observation, record review, and interview, the facility failed to ensure inspection of u-bars was part of their regular maintenance program for 1 (#38) of 1 sampled resident reviewed for accident hazards related to bed rails.The DON identified one resident utilized bed rails.Findings: On 05/05/26 at 12:00 p.m., the bed for Resident #38 was observed to have a u-bar (a type of bed side rail) on the right side of their bed. On 05/05/26 at 2:21 p.m., Resident #38 was observed in their bed with their eyes closed with a u-bar on the right side of the bed. A Bed Safety policy, dated December 2007, read in part, Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. …
F909 citations in Oklahoma
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
Oklahoma cites F909 more often than its own record predicts
4.43 times the share F909 takes of citations nationally.
Of every deficiency written in Oklahoma 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 Oklahoma surveyors wrote
F909 findings written in Oklahoma, 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 Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 0.96% | 6.77× |
| 2024 | 0.64% | 5.40× |
| 2025 | 0.48% | 4.43× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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