Based on observation and interview, the provider failed to ensure the bed/side rails for three of three sampled residents (3, 5, and 8) who had side rails on their beds were inspected for safety, including entrapment (being caught between bed system parts) risk, before being placed on the residents' beds and were monitored after installation to ensure they were maintained in safe conditions for use and free of entrapment risks.Findings include: 1. Observation on 8/20/25 at 2:48 p.m. with resident 5 revealed her bed had one-fourth-size side rails attached to the sides of her bed, and they were in the up position. 2. Observation and interview on 8/21/25 at 10:45 a.m. with resident 8 revealed her bed had a side rail on the right side of her bed, in the up position. 3. …
F909 citations in South Dakota
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
South Dakota cites F909 more often than its own record predicts
7.71 times the share F909 takes of citations nationally.
Of every deficiency written in South Dakota 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 South Dakota surveyors wrote
F909 findings written in South Dakota, 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 South Dakota citations | vs expected |
|---|---|---|
| 2024 | 0.90% | 7.58× |
| 2025 | 0.84% | 7.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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