Failure to Document Zone 1 Entrapment Measurements
Summary
The facility failed to document Zone 1 entrapment measurements for 18 out of 20 residents who were reviewed for side rail use. Zone 1 is identified as the open space within the perimeter of a bed rail, and its measurement is crucial to prevent resident entrapment. The absence of documented evidence for Zone 1 measurements was observed across multiple residents, including those with cognitive impairments and physical disabilities, who relied on side rails for mobility and positioning. This oversight was confirmed through interviews with the Maintenance Director and staff, who acknowledged that the Zone 1 measurements were not documented on the Bed System Measurement Device Test Results Worksheets. The facility also failed to conduct monthly entrapment measurements as outlined in the residents' care plans. Despite the care plans specifying the need for monthly measurements to ensure safety, the Maintenance Director admitted that these measurements were not performed, as they believed the measurements would not change. This lack of adherence to the care plans posed a risk of not identifying potential entrapment areas, which could lead to serious harm for the residents. Observations and interviews revealed that residents with severe cognitive impairments and physical limitations were using side rails for assistance with bed mobility and positioning. However, the facility's documentation did not reflect the necessary safety checks for these enablers. The Maintenance Director and staff were responsible for the bed inspections, which included visual checks but not the required entrapment measurements. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiencies in the facility's processes.
Penalty
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A resident with severe cognitive impairment and multiple neurologic and vascular diagnoses was observed on multiple occasions lying on an air mattress that was too small for the bedframe, resulting in the resident’s feet and head extending beyond the mattress and a gap of about one foot between the mattress and the bedframe. A CNA, the ADON, and the DON each confirmed that the mattress did not properly fit the bedframe and did not accommodate the resident’s height.
The facility failed to maintain a documented, routine program for inspecting bed frames, mattresses, and bed rails for safety and entrapment risks. Although a resident’s bed and four other beds with air mattresses and side rails were observed by the DON and found to have proper mattress fit and no unsafe gaps, the Maintenance Supervisor stated that while he measures and assesses beds for proper fit and entrapment hazards when placing new mattresses, he does not document these assessments and does not perform regular, scheduled safety checks of all beds.
Surveyors found that the facility did not conduct or document required safety inspections of any of the 77 resident beds, including those with assist or mobility bars. The NHA confirmed there was no policy for bed inspections, and the Maintenance Director reported that while informal checks are done at admission (such as removing safety bars, checking for a mattress, testing remotes, and looking for exposed wires), these checks are not documented. Review of the MIFU for Joerns beds showed a requirement for monthly visual inspections for broken welds, cracks, and loose hardware, which were not documented. Additionally, although FDA guidance on seven bed entrapment zones and dimensional limits was available, the Maintenance Director stated that FDA entrapment zone measurements were not performed or documented for any of the 36 residents using bed rails, mobility bars, or assist bars.
A resident with multiple medical conditions was found to have a low air loss mattress that overhung the bed frame by about five inches, preventing the installation of a grab bar on one side. The Maintenance Director confirmed the mattress was too large for the frame and not fully supported.
The facility failed to perform regular inspections and maintenance of bed frames, mattresses, and bed rails for multiple residents, as required to identify possible entrapment areas and ensure that bed components were safely attached. During interviews, the DON and the Administrator confirmed that bed evaluations, assessments, and routine maintenance had not been completed as expected and acknowledged that this did not meet their own safety expectations.
The facility failed to conduct and document routine safety inspections of bed frames and side rails used by a resident with intact cognition who was repeatedly observed in bed with bilateral quarter side rails in the up position around the shoulders and head. The maintenance supervisor reported that beds and rails were only checked and repaired when issues were reported, and there was no established program for routine inspections. The DON believed beds and rails were inspected before use but confirmed there was no documentation of such inspections and no policy or procedure governing bed frame and bed rail use and inspection.
Incompatible Mattress and Bedframe for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s mattress was compatible with and properly fit the bedframe, as required by the expectation that all bed frames, mattresses, and bed rails be regularly inspected for safety and that mattresses attach safely to the bed frame. The affected resident had an admission date of 12/07/2023 and diagnoses including Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease, with a Quarterly MDS BIMS score of 6 indicating severe cognitive impairment. On 03/23/2026 at 11:39 a.m., surveyors observed the resident lying in bed with his feet hanging off the mattress, which appeared too small for the bedframe. On 03/24/2026 at 10:12 a.m., further observation showed the resident lying on his back with his head elevated on an air mattress that did not fit the bedframe properly, leaving approximately a 1-foot gap between the top of the bedframe and the head of the mattress, with the resident’s head partially above the mattress. At 12:48 p.m., a CNA confirmed the mattress did not fit the bedframe and explained that pulling the resident and mattress up in the bed would create a gap at the footboard. At 1:00 p.m., the ADON confirmed the mattress was not accommodating to the resident’s height and should be. At 3:00 p.m., the DON observed that the air mattress was approximately 1 foot smaller than the bedframe and confirmed that the bed was not accommodating the resident and that the mattress did not fit the bedframe properly.
Lack of Documented and Ongoing Bed Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document regular inspections of all bed frames and mattresses as part of a maintenance program to ensure mattress–bed frame compatibility and identify areas of entrapment. During an observation of one resident’s bed with the DON, the mattress was found to fit the bed frame appropriately, and no unsafe gaps were noted around the quarter bedrails; additional observations of four other residents’ beds with air mattresses and side rails also revealed no entrapment or safety issues. In an interview, the Maintenance Supervisor reported that he measures bed mattresses and frames to ensure proper fit and assesses the mattress, frame, and bed rails for gaps or entrapment hazards when placing a new mattress. However, he acknowledged that he does not document these assessments and does not have a regular, ongoing maintenance program for checking beds for safety, leading to the cited deficiency.
Failure to Inspect and Document Safety of Beds and Bed Rails per MIFU and FDA Guidance
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document required inspections and safety assessments of resident beds, including bed frames, mattresses, and bed rails or assist/mobility bars. Surveyors observed resident beds with assist/mobility bars in use. During interviews, the Nursing Home Administrator stated there were no bed inspections being conducted and confirmed there was no policy regarding bed inspections. The Maintenance Director reported that when a new admission is anticipated, maintenance staff go to the room, remove safety bars, ensure a mattress is present, inspect the bed, test the remote, and check for exposed wires, and that therapy may later order safety bars or bed extensions or special mattresses. However, the Maintenance Director acknowledged that these inspections are not documented. Review of the Manufacturer’s Instructions for Use (MIFU) for Joerns Model U770, U790, and U795 beds showed that the beds and accessories are to be visually inspected monthly for broken welds, cracks, and loose hardware, and that any bed with such defects must be removed from service and repaired. The facility did not document that these monthly inspections were performed for any of the 77 resident beds. In addition, review of FDA guidance on hospital bed system entrapment risks identified seven potential entrapment zones and recommended dimensional limits for zones 1–4. The Maintenance Director stated that although they have reference sheets describing the seven or eight entrapment zones and related measurements, the facility does not perform or document FDA entrapment safety zone measurements for any of the 36 residents identified as having bed rails, mobility bars, or assist bars.
Incompatible Mattress and Bed Frame Resulting in Unsafe Bed Setup
Penalty
Summary
The facility failed to ensure that a mattress and bed frame were compatible for a resident with morbid obesity, muscle weakness, and Type II Diabetes Mellitus. The resident, who was cognitively intact and required a low air loss mattress at all times, reported that the mattress was too large for the bed frame. Observation confirmed that the mattress overhung the bed frame by approximately five inches, and a grab bar could not be installed on one side of the bed due to the mattress's size. The Maintenance Director acknowledged that the mattress was not fully supported by the frame and confirmed awareness of the issue.
Failure to Perform Regular Bed Safety Inspections and Maintenance
Penalty
Summary
The facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 13 residents. Surveyors determined that bed evaluations, assessments, and regular maintenance, which should have been completed for all residents’ beds, had not been done. The deficiency involved the lack of routine safety checks to ensure that all bed rails and mattresses were safely attached to the bed frames and to identify potential entrapment zones between the mattress, side rail, footboard, and headboard. During an interview, the DON and the Administrator acknowledged that bed evaluations, assessments, and regular maintenance for residents’ beds were expected to be completed but had not been carried out, and they stated that this did not meet their expectations for safety. The report cross-referenced related findings under tag 700A, indicating that the identified issue was part of a broader concern regarding bed safety inspections and maintenance.
Failure to Conduct and Document Routine Bed and Side Rail Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine inspection of a resident’s bed and side rails, as required for safety. One resident was repeatedly observed in bed with bilateral quarter side rails in the up position around the shoulders and head on multiple dates, with the rails attached to the bed frame. An annual MDS assessment showed this resident had a BIMS score of 13, indicating intact cognition and normal memory and thinking abilities. Despite the ongoing use of these bed rails, there was no evidence that the bed frame or side rails had been routinely inspected for safety. During interviews, the maintenance supervisor, who had been in the role for 1.5 years, stated that their practice was to repair beds or rails only when an issue was reported and to assemble new beds when they arrived, but confirmed there was no program for routine inspection of bed frames and bed rails. The DON stated they believed beds and bed rails were inspected before resident use but acknowledged there was no documentation of such inspections. The DON also confirmed there was no policy or procedure in place regarding the use and inspection of bed frames and bed rails. These actions and inactions resulted in the failure to conduct and document routine safety inspections for beds and side rails used by residents.
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