1 of 9 reviewed for bedrailsBased on interview and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails for 1 of 9 residents (R11) reviewed for bed rails.R11 did not have alternatives attempted prior to the facility installing and utilizing bed rails.R11's bed rail assessment was not completed accurately.R11's bed rail assessment and consent form were not updated after the installation of an air mattress.R11's… …
F700 citations in Wisconsin
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
Wisconsin cites F700 more often than its own record predicts
1.12 times the share F700 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F700 findings written in Wisconsin, 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 did not attempt the use of alternatives, or assess for the risk of entrapment prior to the use of bed rails for 1 of 1 sampled residents with bed rails which resulted in injury for the resident. The facility also did not complete assessments for 7 of 7 residents for the use of bed rails. Resident (R) 30 was not assessed for the risk of entrapment prior to installing bed rails. R30 fell on [DATE] and her left arm became entrapped resulting in a fracture. R37, R4, R8, R9, R39, R14 and R29 have bed rails in use. The facility did not try alternative measures first or assess for the risk of entrapment prior to using the bed rails. This is evidenced by: 1. R30 was admitted to the facility with [DIAGNOSES REDACTED]. …
Based on observation, record review and interview, the facility did not assess the risk of entrapment and review the risk and benefits for 2 residents (R1 and R27) of 2 residents observed having bed rails. *) R1 was observed to have bilateral grab bars to bed without an assessment. *) On 7/29/26, R27 was observed in bed with a left quarter side rail up. R27's ADL (activity daily living) care plan initiated 8/13/25 & revised 8/14/25 includes an intervention initiated 8/13/25 & revised 11/3/25 of bed mobility: assist of 1 with use of bilateral enabler bars. R27's side rail assessment dated [DATE] includes documentation of left sided mobility bar. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.33% | 0.90× |
| 2024 | 0.45% | 1.06× |
| 2025 | 0.44% | 1.12× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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