F909: 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
F909 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: 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.
It sits in CMS's environmental category.
CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.
How seriously inspectors rate it
Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 9.4% of F909 citations came from a complaint visit rather than a routine inspection.
By letter: C 1, D 270, E 170, F 43, G 4, K 1.
What inspectors wrote
Three recent F909 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.
Inspectors wrote, July 17, 2026, scope and severity DBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, specialty air filled mattress for residents to prevent bed sores) fit the bedframe size and did not have any gaps between the grab bar and the LALM for one in one resident (Resident 53). This failure had potential for Resident 53 to be caught, trapped, or entangled in the gaps and to sustain injuries.
The Gardens Healthcare Center, Northridge, CA
Inspectors wrote, July 9, 2026, scope and severity GBased on record review and staff interviews, the facility failed to ensure that a circular bed rail was maintained in safe working condition. As a result, the rail did not remain secure, and the resident fell from the bed during care sustaining a fractured femur (the long thigh bone). This deficient practice affected 1 of 1 resident (Resident #1) reviewed for bed rails.
Woodhaven Nursing Center, Lumberton, NC
Inspectors wrote, July 8, 2026, scope and severity DBased 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.
Southern Oaks Therapy and Living Center, Dallas, TX
Most recent F909 citations at the harm or jeopardy level
Newest first, all 5 in the current files. Each home's page shows the citation in full context, with its correction status.
| Inspection | Home | Town | Letter | Visit |
|---|---|---|---|---|
| July 9, 2026 | Woodhaven Nursing Center | Lumberton, NC | G | Complaint |
| July 22, 2025 | Ely Manor | Allegan, MI | G | Complaint |
| April 9, 2025 | High View Rehabilitation and Living Center | Madawaska, ME | K | Standard |
| February 13, 2025 | Smith Village | Chicago, IL | G | Complaint |
| May 30, 2024 | Accura Healthcare of Le Mars | Le Mars, IA | G | Complaint |
Most recent F909 citations
F909 citations by state
Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.
By inspection year: 2019 6, 2020 4, 2021 18, 2022 38, 2023 109, 2024 143, 2025 118, 2026 53.
Common questions
- What is F909 in a nursing home inspection?
- F909 is the federal requirement to "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". CMS files it under environmental. A home cited under F909 did not meet that requirement at the inspection.
- How often is F909 cited?
- The CMS files as of September 1, 2026 list 489 F909 citations at 458 nursing homes, 77 of them in the 12 months to that date. 1.0% were rated as actual harm or immediate jeopardy.
- Is a F909 citation serious?
- It depends on the letter. Most F909 citations (98.8%) were rated as potential for more than minimal harm, D to F. 1 were immediate jeopardy, the most serious level.
The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology