Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a bariatric (a specialized medical support surface engineered for patients with a high body mass index) mattress was compatible with a bed frame for (1) one of (15) fifteen sampled residents, Resident #24. Resident #24's bariatric mattress measured 46 (forty-six) inches and was placed on a bed frame that extended to 42 (forty-two) inches, resulting in an overlay. While being provided with incontinence care on 03/13/2026, Resident #24 fell out of bed landing face down between the bed and the wall. Resident #24 sustained a hematoma to the forehead and a laceration to the bridge of the nose, resulting in transfer to a higher level of care, thus constituting harm. …
F909 citations in Virginia
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
Virginia cites F909 more often than its own record predicts
1.41 times the share F909 takes of citations nationally.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F909 findings written in Virginia, 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 staff interview, clinical record review, facility document review, the facility staff failed to conduct bed and bed rails inspections for one of 80 residents in the survey sample, Resident #125 (R125). The findings include:For Resident #125 (R125), facility staff failed to conduct a bed and bed rail safety inspection. R125 was admitted to the facility with a diagnosis that included but not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/29/2026, R125 scored 2 15 out of 15 on the BIMS (brief interview for mental status), indicating R125 was cognitively intact for making daily decisions. On 02/03/2026 at approximately 3:33 p.m. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.33% | 2.33× |
| 2024 | 0.37% | 3.16× |
| 2025 | 0.15% | 1.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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