Failure to Include Bed Rails in Routine Preventative Maintenance Program
Penalty
Summary
The deficiency involves the facility’s failure to include a resident’s bed rails in a routine, preventative maintenance program as required by the facility’s bed safety procedures. On 12/10/25 at 1:48 PM and again at 3:38 PM, surveyors observed Resident 18 in bed with bilateral quarter bed rails in the up position. During a combined interview on 12/11/25 at 11:35 AM with the NHA (E1) and DON (E2), surveyors reviewed the requirement that bed rails be inspected as part of the facility’s maintenance program. At that time, the facility was unable to provide evidence that this resident’s bed rails had been included in any routine, preventative maintenance inspections prior to 12/10/25. On 12/12/25 at 12:30 PM, this finding regarding the lack of documented preventative maintenance for the resident’s bed rails was reviewed with facility leadership, including the NHA, DON, and ADON, during the exit conference.
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