Based on record review, interview, and review of the facility's policy on proper use of side rails, the facility failed to conduct regular inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for Resident #9 (1 of 2 residents reviewed for accidents). The findings included: Resident #9 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's physician's orders [REDACTED]. Review of Resident #9's discharge summary revealed that the resident received hospice care and expired on [DATE]. …
F909 citations in South Carolina
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 — 2023
South Carolina cites F909 more often than its own record predicts
3.34 times the share F909 takes of citations nationally.
Of every deficiency written in South Carolina in 2023, 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 South Carolina surveyors wrote
F909 findings written in South 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.
Based on observation, record review, interviews, and facility policy review, the facility failed to ensure bed rails were inspected and maintained per the facility policy for two of seven residents (Resident (R) 11 and R14) reviewed for accidents out of 26 sampled residents. There was no evidence that the residents' beds were appropriately inspected and maintained to ensure the installed side rails were safe for residents' use. This failure placed the residents at risk for risk of entrapment. …
What else South Carolina surveyors cite →
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