On 03/09/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to accurately assess resident #1 for the risks of entrapment from bed rails. The bed rails were contraindicated according to the resident's 05/26/20 bed rail evaluation. The resident was entrapped by the bed rails and sustained a laceration to her right mandible on 12/27/20. The resident's bed was observed on 03/08/21 and verified by staff to have the same air mattress and bed rails as it did when the previous entrapment occurred. The resident had the likelihood of being seriously injured because of the continued use of the bed rails. On 03/09/21 at 12:32 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. …
F700 citations in Oklahoma
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
Oklahoma cites F700 more often than its own record predicts
1.44 times the share F700 takes of citations nationally.
Of every deficiency written in Oklahoma 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 Oklahoma surveyors wrote
F700 findings written in Oklahoma, 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 ensure assessments were conducted for bedrails for 1 (#1) of 1 sampled residents who were reviewed for bedrails.CNA #1 identified six residents who had bedrails.Findings: On 03/10/26 at 8:44 a.m., Resident #1 was observed in bed. An enabler style bedrail was observed on the right side of the bed, in the up position. A physician order, dated 12/22/25, showed Resident #10 may use an enabler style bedrail to assist with positioning. A care plan, revised 12/27/25, read in part, 12/22/2025-Transfer bar evaluation with demonstration completed for safety of repositioning while in bed and transferring in and out of bed safely. …
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 1.47% | 3.94× |
| 2024 | 1.62% | 3.80× |
| 2025 | 0.56% | 1.44× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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