Based on observations, record review, and interviews, the facility failed to ensure correct installation, use, and maintenance of bed rails (side rails, safety rails, grab bars, assist bars, enabler bars) to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for four of four residents (Residents #3, #10, #12, #101, and #112) reviewed. Specifically, Resident #10's bed rail failed the entrapment zone test in Zone 3 (space between the mattress and the bed rail); Resident #101's bed rail failed the entrapment zone test in Zone 1 (space within the bed rail itself); and Residents #3, #10, #12, #101, and #112 did not have routine inspections of their mattress and/or bed rails for areas of possible entrapment. …
F700 citations in New York
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 York cites F700 more often than its own record predicts
1.22 times the share F700 takes of citations nationally.
Of every deficiency written in New York 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 York surveyors wrote
F700 findings written in New York, 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 interview during the abbreviated survey (NY 263) conducted on 11/24/21, the facility failed to ensure attempts were made to use appropriate alternatives prior to installing a side or bed rail; failed to assess residents for risk of entrapment from bed rails prior to installation; failed to review the risks and benefits of bed rails with the resident or resident representative, and failed to obtain informed consent prior to installation for 2 of 6 residents (Residents #1 and 2) reviewed. …
Based on observation, interview, and record review conducted during a survey, the facility failed to follow the manufacturers' recommendations and specifications for installing and maintaining bed rails for two (2) (Resident #2 and Resident #74) of two (2) residents reviewed. Specifically, Resident #2 and Resident #74 had a bed assist rail that was not secured to its bed frame. The findings include: The facility policy and procedure titled Transfer/Bed Mobility Bar, revised 02/24/2026, documented when installing transfer bars, the facility would follow manufacturer recommendations to ensure that the transfer bars were compatible with the bed frame and mattress and follow manufacturer instructions to ensure bed rails did not pose a risk for entrapment. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.21% | 0.56× |
| 2024 | 0.53% | 1.23× |
| 2025 | 0.48% | 1.22× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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