Based on observation, interview, and record review, the facility failed to ensure five of five Residents (Residents 6, 8, 11, 16, and 55) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 6 had two bed rails raised up and had sustained an injury of unknown origin on [DATE] prompting the facility to pad the bed rails. …
F700 citations in California
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.
Against expectation — 2025
California cites F700 more often than its own record predicts
1.19 times the share F700 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F700.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F700 findings written in California, 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 observation, interview, medical record review, and facility P&P review, the facility failed to obtain a physician's order prior to the use of bed rail for one of two final sampled residents (Resident 60) reviewed for the use of bed rails. * The facility failed to obtain a physician's order prior to Resident 60's use of left bed rail. This failure had the potential to put the resident at risk for serious injuries.Findings: Review of the facility's P&P titled Proper Use of Bed Rails revised 5/18/26, showed upon receiving informed consent, the facility will obtain a physician's order for the use of specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. …
Based on observation, interview and record review, the facility failed to ensure the resident, who had half bed siderails up, was assessed prior to installation of bed rails for one of 14 sampled residents (26). This deficient practice had the risk of unnecessary use of bed siderails. Findings: During initial tour of the facility on 10/13/18, at 7:30 am and throughout the survey, Resident 26 was observed lying in bed with half siderails up. According to Resident 26's admission record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.52% | 1.39× |
| 2024 | 0.63% | 1.47× |
| 2025 | 0.46% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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