This deficient practice pertains to Intake #3120666.Based on observation, interview, and record review, the facility failed to:Complete comprehensive bed rail assessments to determine initial resident need and continued need for bed rails,Trial or provide rationale against less restrictive alternatives to bed rail use,Assess all residents with bed rails for risk of entrapment and ensure the absence of bed entrapment zones through consistent and scheduled measurements by facility staff, and/orEnsure informed consent was obtained prior to installation of bed rails.This deficient practice resulted in an Immediate Jeopardy (IJ) due to the death of one Resident (#1) and the likelihood of entrapment and/or serious harm for four additional Residents (#2, #3, and #4) out of four residents reviewed… …
F700 · Bed rails
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F700 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F700 finding.
The harm level
How severely F700 is cited
2.6% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J150.9% | K211.2% | L30.2% |
| Actual harm | G60.3% | H— | I— |
| No harm, potential for more than minimal | D1,05661.3% | E58734.1% | F331.9% |
| No harm, potential for minimal | A— | B— | C10.1% |
In the surveyor’s words
What an F700 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and staff interview, the facility failed to ensure the correct use and ongoing reassessment of bed siderails for one of one resident, Resident ID #1 reviewed for the use of bed siderails. The facility failed to reassess the continued need for and safety of the resident's bed siderails for approximately 15 months, despite the resident's severely impaired cognition, total dependence for bed mobility, and continued use of the device. Consequently, the facility failed to identify that the bed siderails had become unsafe and were no longer clinically appropriate. As a result, Resident ID #1 sustained a traumatic posterior (the back) dislocation of the right shoulder and significant bruising. …
Based on observation, interview and document review, the facility failed to ensure residents with attached grab bars were comprehensively assessed for use for 1 of 3 residents (R16) whom had grab bars. Findings include:R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 was cognitively aware and had diagnoses that included dementia, adult failure to thrive (FTT), and major depressive disorder. R16 was dependent on staff in all care areas.R16's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 6/23/26, identified R16 had an alteration activity of daily living (ADL) self-care performance related to weakness from diagnosis of FTT and some noted confusion with diagnosis of dementia. …
Based on review of policies and procedures with the Compliance Officer (employee #2) on 09/24/2024 at 1:28 PM, it was determined that the facility failed to ensure the risks and benefits of bedrails for residents. The facility must ensure the proper installation, use and maintenance of bedrails. Findings include: 1. During the review of the procedure's manual, the policy and procedure with professional standards of bedrails practice. The Compliance Officer (employee #2) were interviewed to see if they could find it in the manual. The facility did not ensure that the handrail restrictions included risk review and consent to meet the resident's needs.
By state — 2025
Where F700 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Louisiana3.39× · 28 citations
- Missouri2.52× · 37 citations
- California1.19× · 73 citations
- Texas0.77× · 29 citations
Co-occurrence
Cited alongside F700
Of the 2025 surveys that cited F700, these tags appeared in the same inspection more often than chance would predict.
- F90911.4% of F700 surveys · 25.2× chance
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.
- F6048.8% of F700 surveys · 5.6× chance
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- F75813.5% of F700 surveys · 5.2× chance
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- F55210.2% of F700 surveys · 4.5× chance
Ensure that residents are fully informed and understand their health status, care and treatments.
- F5827.1% of F700 surveys · 4.2× chance
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Cited in the same inspection, not caused by one another.
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