The facility had a census of 31 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to assess and identify risks for Resident (R)1, who was severely cognitively impaired, regarding the use of side rails and further failed to place bolsters (a long thick pillow that is placed under other pillows for support) as required to prevent entrapment when side rails and an air mattress were used concurrently. On [DATE] facility staff placed side rails on R1's bed, already equipped with an air mattress, to assist R1 with bed mobility. The facility did not place a bolster per policy to protect R1 from entrapment. On [DATE] R1 experienced a significant change and was placed on hospice services. …
F700 citations in Kansas
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
Kansas cites F700 more often than its own record predicts
1.24 times the share F700 takes of citations nationally.
Of every deficiency written in Kansas 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 Kansas surveyors wrote
F700 findings written in Kansas, 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 interview, observation, and record review, the facility failed to obtain informed consent from the residents or the resident's legal representative for installation of bedrails for Resident (R) 10, R14, R1 and R39. Findings include:1. The Electronic Health Records (EHR) for R10 included diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side (severe functional limitations, including balance issues, reduced mobility, and possible communication difficulties, requiring a multidisciplinary rehabilitation approach), blindness in right eye, muscle weakness, and… …
The short window
Recent years
| Year | Share of Kansas citations | vs expected |
|---|---|---|
| 2023 | 0.86% | 2.31× |
| 2024 | 0.74% | 1.74× |
| 2025 | 0.48% | 1.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kansas surveyors cite →
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