Based on observation, interview, and record review, it was determined that the facility failed to: Part A.) ensure side rails were installed and maintained in a safe, secure manner and without gaps between the side rails and the mattress to prevent entrapment risks for 3 of 38 residents reviewed for quality of care (Resident #3, #17, and #18) on 2 of 5 units (Court 1 and Pavilion Unit). In addition, the facility failed to reduce additional entrapment risks when durable medical equipment (a geri-chair and a wheelchair) were locked and adjacent to the bed frames on the low ends of the bed. The surveyors observed one of the residents with their head in the gap between the mattress and the side rail, the side rail padding was covering their face, and the resident was screaming. …
F700 citations in New Jersey
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
New Jersey cites F700 more often than its own record predicts
1.53 times the share F700 takes of citations nationally.
Of every deficiency written in New Jersey 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 New Jersey surveyors wrote
F700 findings written in New Jersey, 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, interviews, record review, and policy review, the facility failed to ensure alternative interventions were attempted prior to the use of side rails, failed to document discussions regarding the risks and benefits of side rail use, and failed to obtain signed informed consent prior to implementing side rails for one of three residents (Resident (R) 78) reviewed for side rail use out of 30 sampled residents. This deficient practice placed R78 at risk for inappropriate restraint or side rail entrapment. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.43% | 1.16× |
| 2024 | 0.50% | 1.18× |
| 2025 | 0.60% | 1.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction