Based on observation, record review, and interview, the facility failed to ensure ongoing assessments for a change in condition for the use of side rails of a dependent resident which resulted in a side rail entrapment, a fall, and subsequent [MEDICAL CONDITION]'s right arm for 1 of 3 residents reviewed for side rails. (Resident 106) Finding Resident 106's clinical record was reviewed on 6/18/19 at 1:37 p.m. [DIAGNOSES REDACTED]. A Bed Rail Safety Assessment, dated 10/4/18, indicated Resident 106 used the side rails to grab and hold position during personal care, to reposition in bed, and to provide a feeling of comfort and security by establishing bed boundaries. Safety concerns indicated the resident was unable to transfer to and from bed safely. …
F700 citations in Indiana
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
Indiana cites F700 less often than its own record predicts
0.29 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana 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 Indiana surveyors wrote
F700 findings written in Indiana, 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 and record review, the facility failed to ensure consents were obtained and the ability to safely use an enabler bar for bed mobility and transfers assessments were completed for 2 of 7 residents reviewed for accident hazards. (Resident 115 and 11)Findings include:1. During an observation, on 12/11/25 at 12:03 p.m., Resident 115 was in bed and had bilateral grab bars. During an observation, on 12/12/25 at 2:02 p.m., Resident 115 was in bed and had bilateral grab bars. During an observation, on 12/15/25 at 10:04 a.m., Resident 115 was in bed and had bilateral grab bars. During an observation, on 12/16/25 at 10:32 a.m., Resident 115 was in bed and had bilateral grab bars. The clinical record for Resident 115 was reviewed on 12/12/25 at 2:31 p.m. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 0.20× |
| 2024 | 0.23% | 0.55× |
| 2025 | 0.11% | 0.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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