Health inspection·June 12, 2025

Empress Care Center Recertification Survey Event ID 4H9411 Exit Date 4/28/25 State Citation B was written. F700 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. From 4/21/25 to 4/28/25, an unannounced recertification survey and extended survey was conducted at the facility. The facility failed 1. To complete the bed rail entrapment assessment for 48 of 48 patients (1, 28, 8, 3, 26, 14, 5, 25, 99, 37, 19, 24, 15, 44, 2, 13, 6, 10, 33, 32, 42, 249, 39, 31, 36, 250, 21, 4, 251, 252, 23, 20, 38, 199, 40, 46, 34, 30, 17, 11, 18, 29, 9, 7, 22, 12, 27, and 200); 2. To attempt alternatives measures for 6 of 48 patients (4, 33, 44, 99, 249, and 250) prior to implementing the bed rails; and 3. To complete the bed rail care plan for one of 48 patients (40). These failures had the potential to place the patients at risk of entrapment and serious injury. 1. During observations on 4/21/25, from 9:25 a.m. to 10:52 a.m., Patients 13, 6, 10, 33, 32, 42, 249, 39, 31, 36, 250, 21, 4, 251, 252, 23, 20, and 38 had bilateral bed rails up. Review of Patients' 13, 6, 10, 33, 32, 42, 249, 39, 31, 36, 250, 21, 4, 251, 252, 23, 20, and 38 clinical records indicated they did have the entrapment assessments completed for the use of bed rails. During observations on 4/21/25, from 10:49 a.m. to 1:17 p.m., Patient 11 had left bed rail up; Patient 18 had right bed rail up; Patients 199, 40, 46, 34, 30, 17, 29, 9, 7, 22, 12, 27, and 200 had bilateral bed rails up. Review of Patients' 199, 40, 46, 34, 30, 17, 11, 18, 29, 9, 7, 22, 12, 27, and 200 clinical records indicated they did have the entrapment assessments completed for the use of bed rails. During observations on 4/22/25, from 3:36 p.m. to 3:45 p.m., Patient 1 had left side rail up; Patient 3 had right side rail up; Patients 28, 8, 26, 14, 5, 25, 99, 37, 19, 24, 15, 44, and 2 had bilateral bed rails up. Review of Patients' 1, 28, 8, 3, 26, 14, 5, 25, 99, 37, 19, 24, 15, 44, and 2 clinical records indicated they did have the entrapment assessments completed for the use of bed rails. During an interview with the maintenance director (MD) on 4/24/2025, at 1:29 p.m., the MD stated he was not aware of patient's height and weight when measured beds for gap between mattress, bed rails, and safety of patients for using bed rails. The MD also stated applying and removing bed rails upon request by nursing staff based on preferences and need of patient. The MD further stated routinely monitoring function of the beds in facility, unable to provide evidence of documentation monitoring. During an interview with the director of nursing (DON) on 4/24/2025, at 2:14 p.m., the DON confirmed there was no risk for entrapment assessment for use of bed rails for patients. The DON stated facility MD should have coordinated with nursing staff to assess risk for entrapment for patients when using side rails. The DON also stated facility should have assessed patients for risk for entrapment for use of bed rails. During the interview with the DON on 4/24/25, at 2:10 p.m., the DON acknowledged that the maintenance director and nurses should coordinate with each in checking the risks of entrapment and safety of the side rails and patients using them. During the interview with the MD on 4/24/25, at 2:25 p.m., the MD verified that the risks of entrapment and whether the bed rails to be installed were appropriate for the size and weight of the patient were not assessed prior to the installation of the side rails. During another interview with the DON on 4/24/25, at 2:35 p.m., the DON also verified that the risks of entrapment and whether the bed rails to be installed were appropriate for the size and weight of the patient were not assessed prior to the installation of the side rails. She further acknowledged that there should be proper coordination between the nurses and the maintenance director in assessing the side rails for the risks of entrapment and safety of the patients using the side rails and will remind them about that. During an interview with the MD on 4/24/25, at 2:30 p.m., he stated when nursing staff let him know, there would be new admission, he would have the bed and the bed rails ready before the new patient came. After the patient was admitted, if the patient needed only one rail or no rails then he removed them; if the patient needed padded rails, then he padded the rails, but he did not do any adjustment according to the patient's size. The MD stated he did the routine check on the beds and the bed rails, and he only checked on their functions. He did not check or assess the patient's risk for entrapment. 2. During an observation on 4/21/25, at 10:24 a.m., Patient 4's bed had partial bed rails up on both sides. Review of Patient 4's Physical Restraint Assessment, dated 2/18/25, indicated alternative measures were not attempted prior to use of bed rails. During an observation on 4/21/25, at 9:36 a.m., Patient 33's bed had partial bed rails up on both sides. Review of Patient 33's Physical Restraint Assessment, dated 3/5/25, indicated alternative measures were not attempted prior to use of bed rails. During an observation on 4/21/25, at 10:12 a.m., Patient 249's bed had partial bed rails up on both sides. Review of Patient 249's Physical Restraint Assessment, dated 4/11/25, indicated alternative measures were not attempted prior to use of bed rails. During an observation on 4/21/25, at 10:27 a.m., Patient 250's bed had partial bed rails up on both sides. Review of Patient 250's Physical Restraint Assessment, dated 4/11/25, indicated alternative measures were not attempted prior to use of bed rails. During an observation on 4/22/25, at 3:36 p.m., Patient 44 and Patient 99 had bed rails up on both sides. Review of Patient 44's Physical Restraint Assessment, dated 3/19/25, indicated alternative measures were not attempted prior to use of bed rails. Review of Patient 99's Physical Restraint Assessment, dated 4/11/25, indicated alternative measures were not attempted prior to use of bed rails. During an interview with the director of nursing (DON) on 4/28/25, at 11:14 a.m., the DON reviewed Patient 44's and Patient 99's Physical Restraint Assessments and confirmed alternative measures were not attempted prior to use of bed rails for Patient 44 and Patient 99. During an interview with the DON on 4/24/2025, at 2:14 p.m., the DON confirmed there were no alternative attempts prior to starting using bed rails for Patients 4, 33, 249, and 250. The DON also confirmed nursing staff did not complete physical restraint assessment for attempts of alternatives for these patients. The DON stated nursing staff should have attempted and completed assessments for alternatives for bed rails before starting using bed rails for these patients. 3. During the observation of Patient 40 on 4/21/25, at 10:52 a.m., Patient 40 was walking via his front wheel walker, alert, calm, comfortable and verbally responsive to questions. Patient 40's bilateral half side rails were up. Review of Patient 40's Admission Record indicated, Patient 40 was admitted to the facility on 3/4/25. Review of Patient 40's physician orders indicated, Patient 40 had an order of bilateral half side rails up when in bed for turning and repositioning as enabler, ordered on 3/4/25. Review of Patient 40's care plans indicated, there was no care plan for his bilateral half side rails use. Patient 40 had no separate and specific care plan for his side rails. During the concurrent review of Patient 40's care plans and interview with the director of nursing (DON) on 4/24/25, at 11:17 a.m., the DON verified that Patient 40 did not have a separate and specific care plan for his bilateral half side rails. The DON further verified that his side rails should have a separate and specific care plan and would update the care plan of Patient 40. In violation of the above cited standards, the facility failed to ensure proper use of side rails. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.