Based on observation, interview, and record review, the facility failed to ensure bed rails (bed enablers) were properly secured and maintained for safety for 2 of 2 residents (Residents 9 & 29), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.Findings included .Review of the facility's policy titled, Bed Rail, revised on 01/01/2025, showed that the facility would ensure the safe and appropriate use of bed rails in compliance with federal and state regulations, minimize risk of injury, and protect resident rights. …
F909 citations in Washington
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
Washington cites F909 more often than its own record predicts
1.60 times the share F909 takes of citations nationally.
Of every deficiency written in Washington 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 Washington surveyors wrote
F909 findings written in Washington, 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 Washington citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.38× |
| 2024 | 0.27% | 2.31× |
| 2025 | 0.17% | 1.60× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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