Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail or to ensure correct installation, use, and maintenance of bed rails for 1 of 25 residents (Resident #1) reviewed for bed rails. The facility failed to ensure an assessment was conducted for risk of entrapment and that the use of bed rails was added to the care plan for Resident #1prior to installation. Resident #1 became entrapped in her bed rails on [DATE] and found deceased with her head and neck between the rails and her mattress. The noncompliance was identified as Past Noncompliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. …
F700 citations in Texas
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
Texas cites F700 less often than its own record predicts
0.77 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas 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 Texas surveyors wrote
F700 findings written in Texas, 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 attempt the use of appropriate alternatives prior to installing a side or bed rails to include assessing the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation, and ensure that the bed's dimensions are appropriate for the resident's size and weight for 4 of 5 residents (Resident #1, #2, #3, and #4) reviewed for bed or side rails.The facility failed to: obtain consent for bed or side assist rail(s) for residents; have documentation of evaluation for bed or side assist rail(s) for residents; have ongoing monitoring/evaluation for bed or side assist rail(s) for… …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.24% | 0.64× |
| 2024 | 0.39% | 0.92× |
| 2025 | 0.30% | 0.77× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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