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 citations in Michigan
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
Michigan cites F700 less often than its own record predicts
0.48 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F700 findings written in Michigan, 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 assess the risk of entrapment, review bed rail risks and benefits with the resident/resident representative and obtain consent and a physician order prior to the installation of bed rails for 1 Resident (#19) of 1 resident reviewed for bed rail safety. This deficient practice resulted in the potential for bed entrapment and risk of injury and death.Findings include:During an observation on 4/29/26 at 7:30 a.m., R19 was observed lying in bed. A breakfast tray was positioned on an overbed table but R19 was unable to eat independently. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.18% | 0.48× |
| 2024 | 0.19% | 0.45× |
| 2025 | 0.19% | 0.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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