Based on observations, facility documentation, and staff interviews, it was determined that the facility failed to conduct regular inspection of all bed rails/enabler bars as part of a regular maintenance program to identify areas of possible entrapment for one of two residents reviewed with enabler bars (Resident 14). Findings include: Review of Resident 14's clinical record documented diagnoses that included hemiplegia (paralysis or severe weakness affecting one side of the body). Observation in Resident 14's room on December 10, 2025, at 11:30 AM, revealed an enabler bar was on the right side of the bed. Resident 14's physician orders included a right-side enabler for bed mobility and increased independence, start date August 14, 2025. …
F909 citations in Pennsylvania
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
Pennsylvania cites F909 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F909 findings written in Pennsylvania, 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 Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.06% | 0.45× |
| 2024 | 0.04% | 0.33× |
| 2025 | 0.06% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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