F909 in Texas. Pick another state for the same tag.
Against expectation — 2025
Texas cites F909 less often than its own record predicts
Versus expected share0.10×
0.10 times the national share — cited less often here than elsewhere.
Share of Texas citations0.01%
Of every deficiency written in Texas in 2025, this is the portion that was F909.
Texas0.01%
National0.11%
Share of all citations that were F909.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F909 findings written in Texas, 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.
J · Immediate jeopardy, isolatedAugust 21, 2019
Based on observation, interview and record review the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for 1 of 10 Residents (Resident #1) reviewed for bed rails.
The facility failed to follow the manufacturers' recommendations and specifications for installing and maintaining bed rails to identify areas of possible entrapment. Resident #1 was found hanging from the quarter bedrail, her neck and jaw were wedged in the rail. She was blue, unresponsive and had no pulse. Resident #1 was pronounced dead minutes later.
An Immediate Jeopardy was identified that occurred on [DATE]. …
D · No harm, potential for more than minimal, isolatedJuly 8, 2026
Based on observation, interview, and record review, the facility failed to ensure that the bed rails, mattress, and bed frame were compatible for 2 of 6 residents (Resident #2 and Resident #3) reviewed for physical environment. -The facility failed to provide Resident #2 and Resident #3 with a mattress that was functional, comfortable, and appropriate to their needs. This failure could place residents at risk of not having appropriate furniture to accommodate special needs, which could affect their health, comfort, and safety.Findings included:1. Record review of Resident #2's Quarterly MDS Assessment, dated 06/16/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 15, which indicated her cognition was intact. …
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