F909

Based on observation, interview, and record review, the facility failed to identify the existing risk for entrapment of body parts through bed inspections, this failure created the potential for severe bodily injury including death by entrapment of body parts, for 3 of 35 residents [Resident #26 (R26), (R3) and (R13)]. In addition to the resident in immediate jeopardy, the facility's failure to implement an effective inspection of all resident bed equipment (bed frames, mattresses, and bed rails) to ensure that bed mattresses fit the bed frames to prevent entrapment of body parts, this has the potential to effect 35 out of 35 residents with bed rails. Findings: On 3/31/25, the facility's Bed Safety policy, undated, was reviewed. …

High View Rehabilitation and Living Center · Maine

Based on record review and staff interviews, the facility failed to ensure that a circular bed rail was maintained in safe working condition. As a result, the rail did not remain secure, and the resident fell from the bed during care sustaining a fractured femur (the long thigh bone). This deficient practice affected 1 of 1 resident (Resident #1) reviewed for bed rails. Findings included:A review of the facility's Bed and Bedrail Safety Inspection Policy dated 11/2025 indicated that maintenance personnel and clinical staff were responsible for bed safety. The policy indicated that all beds must be inspected regularly to ensure compliance with safety standards. …

Woodhaven Nursing Center · North Carolina

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the resident entrapment assessment was completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of the side rails for one of one final sampled residents (Resident 37) reviewed for side rails. * The facility failed to complete the Zone 4 (gap between the headboard and the halo ring) entrapment measurement for Resident 37's halo safety ring. This failure resulted in an incomplete entrapment assessment and created the potential for resident harm, including entrapment, serious injury, or death. …

Sun Mar Nursing Center · California

Based on observation, interview, and document review, the facility failed to develop and implement a preventative, regular maintenance program of resident' beds and side rails to ensure safety and reduce the risk of complication (i.e., bed malfunction, entrapment) for 3 of 3 residents (R122, R45, R222) reviewed who used side rails on their bed. However, the lack of a program had potential to affect all 75 residents residing at either campus. Findings include: R122's admission Minimum Data Set (MDS), dated [DATE], identified R122 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS included a section labeled, Section P - Restraints, which marked R122 as not using a bed rail with dictation, 0 = Not Used. …

Gundersen St Elizabeth's Care Center · Minnesota