F0909

E

Failure to Conduct and Document Routine Bed and Side Rail Safety Inspections

Salina, Oklahoma Survey Completed on 12-18-2025

Penalty

No penalty information released

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.