Health inspection·August 29, 2025

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)(l) 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 7/21/25 to 7/28/25, an unannounced visit was conducted at the facility for a recertification survey and to investigate two Facility Reported Incidents. Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (SR/BR, adjustable rigid bars attached to the side of the bed) for 30 out of 30 residents when: 1.There was no documentation that indicated the facility follow the policy related to Food and Drug Administration (FDA, a federal agency within the U.S. Department of Health and Human Services responsible for protecting public health by ensuring the safety, efficacy [the power to produce a desired result], and security of human and animal drugs, biological products [substances derived from living organisms and used in medicine for prevention, diagnosis, or treatment], medical devices, our nation's food supply, cosmetics, and products that emit radiation [like smoke detectors, microwave ovens, or wireless devices) entrapment zones for the facility's beds and side rails of30 out of30 residents (Residents 19, 13, 26, 6, 17, 21, 25, 5, 23, 16, 2, 18, 28, 1, 29, 27, 22, 12, 24, 4, 11, 9, 14, 8, 15, 10, 3, 7, 32, and 20), (with bed rails installed in their beds); 2. There was no documentation that indicated the risk of entrapment (a situation where an individual can become caught by their head, neck, chest, or other body pa11s in the tight spaces around the bed rail) assessment from bed rails was completed prior to installation for 30 of 30 residents (Residents 19, 13, 26, 6, 17, 21, 25, 5, 23, 16, 2, 18, 28, 1, 29, 27, 22, 12, 24, 4, 11, 9, 14, 8, 15, 10, 3, 7, 32, and 20; 3. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of side rails for 15 of 15 residents (Residents 19, 13, 26, 6,17, 16, 18,29,22, 7,20, 14, 15,4, and8) who used them; 4. There was no physician's order indicated the use of side/bed rails for 13 (Residents 19, 13, 26, 6, 17, 18, 29, 22, 7, 20, 14, 15, and 4) of 15 residents; 5. There was no person-centered care plans related to side/bed rail used for 15 of 15 residents (Residents 19, 13, 26, 6,17, 16, 18, 29, 22, 7, 20, 14, 15, 4, and 8); 6. Bed Rail Assessment for Residents 21, 25, 5, and 20 had no indication for their use; 7. There was no side/bed rail assessment form completed for 12 (Residents 23, 2, 28, 1, 27, 12, 24, 9, 11, 3, 32, and 10) of 30 residents; and 8. There was no updated "Bed Rail Assessment," completed for Residents 18 and 29. These failures had the potential to place the residents at risk of entrapment and serious injury. 1. During an interview with Plant Operations Manager (POM) on 7/25/2025 at 11:25 a.m., POM confirmed all 30 beds in the facility had bed rails and stated he stopped checking the bed measurements since the director of nursing (DON) told him that the state regulation has changed. POM stated he used to measure the space between the mattress and side/bed rails, the space between the mattress and headboard and the space between the mattress and the footboard. During a concurrent interview with POM and record review on 7/25/2025 at 1:19 p.m., POM reviewed the bed's quarterly inspection and confirmed he inspected all the beds from January 2025 to July 2025. POM confirmed there was no bed measurements for each bed, and he only documented, "YES" to each bed which indicated, "All side rails have an opening of less than 4 inches." POM stated he only measured all four sides of the spaces between the mattress and side rails. During a concurrent observation and interview with POM together with two other nurse surveyors on 7/25/2025 at 1:30 p.m., inside Resident 28's room, there was an upper left and right bed rails installed in the bed and POM confirmed the observation. POM demonstrated how he did the bed inspection and stated he measured the space between the mattress and the bed rail to the left and right side. POM further stated, he also measured the spaces between the mattress and the headboard and between the mattress and the footboard. When asked if he followed the FDA's recommended entrapment zones, POM was unable to demonstrate the other zones to be assessed or measured in the bed. During a review of the FDA's guidance document titled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," dated 8/23/2018, indicated, "Key Areas of Concern and Recommendations: Zone 1: Within the Rail: Open spaces within the bed rail perimeter can pose a head entrapment risk. The FDA recommends a space of less than 43/4 inches. Zone 2: Under the Rail, Between Rail supports: The gap under the rail and above the mattress can be a dangerous entrapment zone. Zone 3: Between the Rail and the Mattress: The space between the inside of the rail and the mattress should be minimized to prevent entrapment. Zone 4: Under the Rail at the Ends of the Rail: The gap between the mattress and the bottom of the rail can cause neck entrapment. The FDA recommends a space of less than 2 3/8 inches. Zone 5: Between Split Bed Rails: When using partial-length rails, the space between them can be a risk zone. Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board: The gap here can also pose a risk of entrapment." During a review of the facility's policy and procedure titled, "Bed Safety and Bed Rails," date revised 8/2022, indicated, "Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. Bed dimensions are appropriate for the resident's use. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. Maintenance staff routinely inspects all bed and related equipment to identify risks and problems including potential entrapment risks. The Maintenance department provides a copy of inspections to the administrator and report results to the QAPI [Quality Assurance and Performance Improvement] committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee." 2. During a concurrent observation and interview with minimum data set nurse (MDSN) on 7/23/2025 at 1:37 p.m., inside Resident 19 and Resident 13's room, Resident 19' s bed had two upper bed rails installed in the bed and the right side/bed rail was in upright position. MDSN confirmed the above observation. At 1:39 p.m., Resident 13 was observed seated on her wheelchair and her bed had two upper bed rails installed but they were not in an upright position. MDSN confirmed Resident 13's bed rail could be pulled up if needed. At 1:40 p.m., Resident 13 stated she used the right upper bed rail when she was in bed to access the bed remote which was located at the right upper bed rail. During a concurrent observation and interview with MDSN on 7/23/2025 at 1:43 p.m., inside Resident 26's room (Resident 26 was not present), Resident 26's bed had four installed bed rails (upper and lower), and the two upper BRs were in an upright position. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/2025 at 1:45 p.m. inside Resident 6's room, Resident 6 was in bed and had four BRs installed. All four BRs were not in use and MDSN confirmed the observations. During a concurrent observation and interview with MDSN and Resident 17 on 7/23/2025 at 1:46 p.m., inside Resident 17' s room, Resident 17 was seated on a chair in front of his computer and his bed had two upper bed rails in place. The left upper bed rail was in an upright position and MDSN confirmed the observations. Resident 17 stated he used the left BR to help him to reposition in bed and with transfer out of bed. During a concurrent observation and interview with MDSN on 7/23/2025 at 1:48 p.m., inside Resident 21's room, Resident 21 had two upper BRs installed in bed. Both upper BRs could be pulled up as needed and MDSN confirmed the observations. During a concurrent observation and interview with MDSN on 7/23/2025 at 1:49 p.m., inside Resident 25's room, Resident 25 had two upper BRs installed in bed and could be pulled up as needed. MDSN confirmed the observations. MDSN stated bed rails were already installed in resident's bed upon admission, and they had to complete the bed rail assessment to determine if the bed rails were indicated to use. During a concurrent observation and interview with MDSN on 7/23/2025 at 1:55 p.m., inside Residents 5 and 23's room, both residents were not in the room, and their beds had upper and lower bed rails in place. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:00 p.m., inside Resident 16's room, Resident 16 was sitting in her wheelchair and verbalized that she was using her side rails, if needed. She had two upper side rails attached to her bed. MDSN verified that Resident 16 would sometimes use her right-side rail if needed. During a concurrent observation and interview with MDSN on 7/23/25 at 2:03 p.m., inside Resident 2 and Resident 18's room, Resident 2 was lying in her bed, confused and could not answer questions. MDSN verified that Resident 2 had bilateral half (2 upper) side rails attached to her bed. Resident 18 was lying in bed, alert and verbally responsive. MDSN verified that Resident 18 had her bilateral half side rails up and she used them. During a concurrent observation and interview with MDSN on 7/23/25 at 2:07 p.m., inside Resident 28's room, Resident 28 had four half side rails attached to her bed. MDSN verified that Resident 28 had four half side rails attached to her bed. During a concurrent observation and interview with MDSN on 7/23/25 at 2:1O p.m., inside Resident 1's room, Resident 1 had four side rails attached to the bed. MDSN verified that Resident 1 had four side rails attached to her bed. During a concurrent observation and interview with MDSN on 7/23/25 at 2:12 p.m., Resident 29's had bilateral half side rails attached to the bed. MDSN verified that Resident 29 had been using either of his side rails, when he's getting up in bed. During a concurrent observation and interview with MDSN on 7/23/25 at 2:15 p.m., inside Resident 27 and Resident 22's room, Resident 27 had four side rails attached to her bed. MDSN verified that Resident 27 had four side rails attached to her bed. Resident 22's bed had the right-side rail in upright position. MDSN verified that Resident 22 had been using her right-side rail. During a concurrent observation and interview with MDSN on 7/23/25 at 2:18 p.m., inside Resident 12's room, Resident 12 had bilateral half side rails attached to her bed. MDSN verified that Resident 12 had bilateral half side rails attached to her bed. During a concurrent observation and interview with MDSN on 7/23/25 at 2:20 p.m., inside Resident 24's room, Resident 24 had bilateral half side rails attached to her bed. MDSN verified that Resident 24 had bilateral half side rails attached to her bed. During a concurrent observation and interview with MDSN on 7/23/25 at 2:22 p.m., inside Resident 4 and 11's room, both residents were sleeping. Resident 4 had the right upper and lower side rails raised and both left upper and lower side rails down. Resident 11 had both upper side rails down. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:23 p.m., inside Resident 9's room, both upper and lower side rails were down. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:24 p.m., inside Resident 14 and 8's room, both residents were not in the room. Resident 14 had both upper side rails down. Resident 8 had both upper and lower side rails raised. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:26 p.m., inside Resident 15's room, Resident 15 was not in the room, and the bed had both upper and lower side rails down. MDSN stated Resident 15 used the left upper side rails. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:28 p.m., inside Resident IO's room, Resident 10 was sleeping, and the bed had both upper side rails down. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:30 p.m., inside Resident 3's room, Resident 3 was not in the room, and the bed had both upper side rails down. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:32 p.m., inside Resident 7 and 32's room. Resident 7 was not in the room, and the bed had both upper and lower side rails down. MDSN stated the side rails were used to transfer Resident 7 from bed to wheelchair. Resident 32 was in the room sleeping, and the bed had both upper and lower side rails down. MDSN confirmed the above observation. During a concurrent observation and interview with MDSN on 7/23/25 at 2:33 p.m., inside Resident 20's room, the resident was sitting in the wheelchair, and the bed had both upper and lower side rails down. Resident 20 stated she does not use the side rails. MDSN confirmed the above observation. During a concurrent interview with MDSN and record review on 7/23/2025 at 2:34 p.m., MDSN reviewed Resident 19's BR assessment completed on 5/23/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/23/2025 at 2:48 p.m., MDSN reviewed Resident 13's BR assessment completed on 4/30/2025 and the SR Rational Screen completed on 5/8/2025. MDSN confirmed the documentation did not indicate an entrapment risk assessment was completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:00 a.m., MDSN reviewed Resident 6's BR assessment completed on 5/23/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:12 a.m., MDSN reviewed Resident 26's BR assessment completed on 5/23/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:18 a.m., MDSN reviewed Resident 17' s BR assessment completed on 5/23/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:22 a.m., MDSN reviewed Resident 21's BR assessment completed on 4/1/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:26 a.m., MDSN reviewed Resident 25's BR assessment completed on 3/18/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:30 a.m., MDSN reviewed Resident 5's BR assessment completed on 3/25/2025 and MDSN confirmed it did not indicate an entrapment risk assessment was also completed. During a concurrent interview with MDSN and record review on 7/24/2025 at 10:34 a.m., MDSN r