CMS F-tag

F909: Environment & safety

Bed rails and beds must be inspected and kept safe. Cited 485 times at 453 nursing homes in the last three inspection cycles.

#112 of 242 tags1% caused harm36 statesLatest survey Dec 22, 2025

How F909 shows up in inspections

F-TAGF909#112 of 242 tagsRarely cited

How serious it usually is

  • Immediate jeopardyK0.2%1
  • Actual harmG0.6%3
  • No actual harmD · E · F99%480
  • Minimal harmC0.2%1

1% of F909 citations involved actual harm or immediate jeopardy. Nationally, about 5% of all citations do.

By the numbers

  • 485Citations
  • 453Facilities cited3% of rated nursing homes

Citations by survey year

  • 20183
  • 201914
  • 20208
  • 202123
  • 202264
  • 2023126
  • 2024146
  • 2025101

Partial years reflect the rolling three-cycle window, not a change in enforcement.

Where F909 is cited most

Survey agencies differ in what they emphasize, so compare a facility with its own state. Shares are the portion of each state’s rated nursing homes with at least one F909 citation.

States by share of facilities cited

  • Missouri18% of homes90 citations · 86 of 479 facilities
  • California6% of homes84 citations · 65 of 1,154 facilities
  • Oklahoma13% of homes40 citations · 37 of 282 facilities
  • Massachusetts10% of homes36 citations · 34 of 338 facilities
  • Virginia11% of homes32 citations · 31 of 285 facilities
  • Maryland10% of homes21 citations · 21 of 219 facilities
  • Illinois3% of homes20 citations · 19 of 665 facilities
  • Washington8% of homes16 citations · 16 of 192 facilities
  • Florida2% of homes14 citations · 14 of 689 facilities
  • Pennsylvania2% of homes14 citations · 14 of 653 facilities

Top 10 of 36 states. Every state page lists its most-cited tags.

Facilities cited most often

  1. Anaheim Healthcare Center, LLCAnaheim, CA · Report card2 F909No harm
  2. Bayshire Yorba Linda Post-AcuteYorba Linda, CA · Report card2 F909No harm
  3. Bluebird Wellness and RehabilitationSaint Louis, MO · Report card2 F909No harm
  4. Colonial Manor Nursing & Rehabilitation HomeRayville, LA · Report card2 F909No harm
  5. Columbia Post AcuteColumbia, MO · Report card2 F909No harm
  6. Coventry Court Health CenterAnaheim, CA · Report card2 F909No harm
  7. Eastview Healthcare & Senior LivingSullivan, IL · Report card2 F909No harm
  8. Eastwood ManorCommerce, OK · Report card2 F909No harm
  9. French Park Care CenterSanta Ana, CA · Report card2 F909No harm
  10. Garden Place HealthcareAttleboro, MA · Report card2 F909No harm
  11. Healthcare Center of Orange CountyBuena Park, CA · Report card2 F909No harm
  12. Kindred Hospital Brea D/P SNFBrea, CA · Report card2 F909No harm
  13. LA Palma Nursing CenterAnaheim, CA · Report card2 F909No harm
  14. Laguna Hills Health and Rehabilitation CenterLaguna Hills, CA · Report card2 F909No harm
  15. Lakeview Post AcuteFlorissant, MO · Report card2 F909No harm

What to ask a facility about a F909 citation

  1. What exactly did the surveyor find, and on what date? The report card shows the date and the severity letter.
  2. What was the plan of correction, and was it accepted by the state on the first submission?
  3. Has the same tag been cited in more than one cycle? Repeat citations matter more than a single one.
  4. If the letter was G or higher: what happened to the resident, and what changed in staffing or process?

Source: CMS Provider Data Catalog, Nursing Home Health Citations, current three inspection cycles, most recent survey Dec 22, 2025. Counts are citations unless labeled facilities.

Frequently asked questions

What is F909 in a nursing home inspection?
F909 is the CMS F-tag for the requirement "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." (Environment & safety). Surveyors cite it when a facility is found out of compliance with that regulation during a standard survey or complaint investigation.
How common is F909?
F909 was cited 485 times at 453 facilities (3% of rated nursing homes) in the last three inspection cycles, ranking #112 of 242 tags. 4 of those citations involved actual harm or immediate jeopardy.
Does a F909 citation mean the facility is unsafe?
Not on its own. Read the scope and severity letter: D through F means no actual harm was found, G through I means a resident was harmed, and J through L means immediate jeopardy. Ask the facility what was cited, what was corrected, and when.

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