HOMER, LA - Federal inspectors cited Presbyterian Village of Homer for significant bed rail safety violations during a May 2025 inspection, finding the facility failed to follow established protocols for assessing and documenting bed rail use for residents.
Critical Safety Assessment Gaps
The inspection centered on Resident #47, whose bed was equipped with turning bars for positioning purposes. While the resident's care plan indicated the turning bars were in place and that "other options have been explored," inspectors discovered multiple critical gaps in the facility's safety protocols.
During observations on May 27 and 28, 2025, inspectors found the resident lying in bed with bilateral positioning bars in the up position. However, the facility had failed to conduct required quarterly assessments for bed rails, performed no assessment for entrapment risk prior to installation, and provided consent forms that did not include proper risk and benefit information.
Medical Safety Standards Violated
Bed rails and positioning devices require comprehensive medical evaluation before implementation. Federal regulations mandate quarterly assessments to ensure continued medical necessity and to evaluate any changes in the resident's condition that might affect safety.
Entrapment risk assessment is particularly crucial, as residents can become trapped between bed rails and mattresses, potentially leading to serious injury or death. The gaps between bed rails, mattress, and bed frame create zones where residents' head, neck, or chest can become wedged, resulting in asphyxiation or strangulation.
Facility Acknowledges Documentation Failures
During interviews on May 29, 2025, facility leadership confirmed the violations. The Maintenance Director, Director of Nursing, Administrator, and Licensed Practical Nurse/MDS Coordinator all acknowledged the absence of required assessments and documentation.
Specifically, staff confirmed there was "no quarterly assessment for bed rails, no assessment for the risk of entrapment prior to installation of bed rails, the consent did not include risk and benefits, no routine inspection of the bed rails, the resident assessment did not contain the components as addressed on the facility's bed rail policy, and there was no documented evidence of the medical need for the use of bed rails."
Industry Standards and Best Practices
Federal nursing home regulations require facilities to minimize the use of physical restraints and ensure that any restraining devices are medically necessary and properly monitored. Bed rails are considered restraints when they prevent a resident from leaving their bed voluntarily.
Proper bed rail protocols should include initial medical assessment documenting the specific need, regular safety inspections, ongoing evaluation of effectiveness, and comprehensive consent processes that outline both benefits and risks. Facilities must also explore less restrictive alternatives before implementing bed rails.
Medical Risks and Consequences
Improper bed rail use poses multiple risks beyond entrapment. Residents may attempt to climb over rails, leading to falls from greater heights and more severe injuries. Some residents experience increased agitation or confusion when feeling confined by bed rails.
Without proper assessments, facilities cannot determine whether bed rails are helping or harming residents. The lack of routine inspections means mechanical problems or wear that could increase entrapment risk may go undetected.
Regulatory Response and Oversight
The Centers for Medicare & Medicaid Services classified this violation under F-tag 0700, indicating issues with quality of care standards. The facility received a "minimal harm or potential for actual harm" rating, affecting some residents.
This citation reflects ongoing federal emphasis on reducing unnecessary restraint use in nursing homes and ensuring that any restraining devices are properly justified, monitored, and documented according to established medical protocols.
The facility must submit a plan of correction addressing how it will implement proper bed rail assessment procedures, staff training, and documentation systems to prevent similar violations in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presbyterian Village of Homer from 2025-05-29 including all violations, facility responses, and corrective action plans.
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