Based on observation, interview and record review, facility staff failed to re-assess bedrail use after a significant change in condition per policy for one resident (Resident #1). Resident #1 was found entrapped in the bedrail, found face down in the mattress and unresponsive, resulting in his/her death. The facility census was 89. The administrator was notified on 09/03/2025 of an Immediate Jeopardy which began on 08/26/2025. The IJ was removed on 09/03/2025, as confirmed by surveyor onsite verification. 1. Review of the facility's Proper Use of Bed Rails policy, undated, showed staff are to ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, or depth. …
F700 citations in Missouri
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
Missouri cites F700 more often than its own record predicts
2.52 times the share F700 takes of citations nationally.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F700 findings written in Missouri, 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 obtain written consent for side rail use, failed to complete a documented side rail assessment, and failed to complete a risk versus benefits side rail assessment for one resident (Resident #1) who got entangled in the side rail when falling out of bed and suffered fractured bone. The facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, and failed to complete a risk versus benefits side rail assessment for three additional residents (Resident #2, #3, and #4). …
Based on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment, review possible risks and benefits of bed rails or trapeze (an overhead assistive device with a suspended triangular handle), and obtain informed consent prior to installation or use for five residents (Residents #8, #84, #162, #172, and #173) out of 33 sampled residents. The facility census was 169.Review of the facility's policy, Bed Rails, revised 06/20, showed: - The assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rails that were attempted and how these alternatives failed to meet the resident's assessed needs; - Before installing a bed rail, the facility must assess the resident for the risk of entrapment from… …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 1.10% | 2.96× |
| 2024 | 1.22% | 2.85× |
| 2025 | 0.98% | 2.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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