Based on observation, staff interview, and review of medical record and complainant documentation, it was determined that prior to the installation of bed rails, the facility: 1) failed to assess resident risks for entrapment 2) failed to obtain consent for bed rail use for cognitively impaired residents, and 3) failed to attempt to use appropriate alternatives prior to installing or using bed rails. After Resident #1 was observed hanging out of the bed on 2/3/23 with his/her head on the floor and feet at or in the bed rails, staff returned him/her into the bed without addressing the bed rails and did not notify facility management of the incident. This concern was evident for 3 (#1, #8, #9) of 3 residents reviewed during a complaint survey. …
F700 citations in Maryland
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
Maryland cites F700 less often than its own record predicts
0.76 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland 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 Maryland surveyors wrote
F700 findings written in Maryland, 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, record review, and staff interview, it was determined that the facility failed to obtain a physician's order prior to the installation and use of bed rails. This was evident for 1 (Resident #91) of 2 residents reviewed for bed rail use.The findings include:On 07/27/2026 at 11:30 AM, observation of Resident #91 revealed bilateral bed rails in the raised position while the resident was in the bed.On 07/28/2026 at 2:25 PM, review of the electronic medical record revealed there was no physician's order authorizing the use of bed rails for Resident #91.On 07/29/2026 at 10:31 AM, review of the facility's bed rail policy revealed that the use of bed rails required a physician's order.On 07/30/2026 at 10:49 AM, during an interview, the Director of Nursing stated that the… …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 1.02% | 2.73× |
| 2024 | 0.43% | 0.99× |
| 2025 | 0.30% | 0.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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