Neighborhoods Rehab: Bed Rail Entrapment Death - MO
The death at Neighborhoods Rehabilitation and Skilled Nursing B triggered an immediate jeopardy finding from federal inspectors, the most serious classification available under the inspection system, one reserved for situations where a facility's failures have placed residents at risk of serious harm or death.
What inspectors found when they pieced together what happened was not a single catastrophic failure but a series of smaller ones, each person responsible for some piece of the bed rail assessment process either unaware of what others had done, uncertain whether anyone had done it at all, or simply unable to remember.
The resident had been hospitalized before the incident. The reason for that hospitalization was a severe hip infection that turned septic. When the resident came back to the facility, the attending physician said he received reports from both the hospital and the facility indicating the resident had developed delirium. He told inspectors, during an interview on September 2, that he and everyone involved were uncertain whether the delirium was acute, a product of the infection, or whether it was going to become the resident's new baseline. A significant change in condition, in other words, was not in dispute.
What was in dispute was whether anyone had reassessed the resident's bed rails after that change.
The assistant administrator told inspectors he was the person responsible for taking measurements for bed rails and putting them on or taking them off. He said he completed a routine check of the resident's bed rails on August 15 as part of the facility's Quality Improvement Plan. He also said August 15 happened to be the same day the resident returned from the hospital.
He could not say what time of day he did the assessment. He could not say whether it was before or after the resident came back. He could not say whether the resident was even in the bed when he looked at the rails.
"Since he/she was not one hundred percent confident with any of the answers," the inspection report states, "he/she does not want to say either way as these are routine for him/her so he/she does not remember."
He also acknowledged he had no documentation to show the assessment had been done at all.
The assistant administrator told inspectors that determining whether a resident is appropriate for bed rails is a nursing question, not his. His role, he said, was mechanical: put them on, take them off. The clinical judgment belonged to someone else.
That someone else, according to RN A, was nursing staff. RN A told inspectors that nurses are responsible for completing the nursing assessment portion of bed rail evaluations, and that the policy calls for reassessment after a significant change in condition to confirm the resident can still safely use the rails. The assessment form, RN A explained, works on a pass-fail basis. No failures on the questions means the resident is considered appropriate for side rails.
RN A said he was not sure whether the resident had experienced a significant change in condition, because he did not know the resident well enough to make that determination. He had been filling in at the facility for a few months, he told inspectors, sent over from a sister facility.
Nobody could confirm that a reassessment had been completed after the resident returned from the hospital with delirium and a history of sepsis. Nobody could confirm one had not been completed, either. What was certain was that there was no documentation of one.
CNA B was the first staff member to find the resident. He walked into the room and saw the resident not moving. The resident was on his knees beside the bed, face leaned against the mattress and the bed rail, not moving. The CNA went to get LPN A.
When LPN A entered the room, the resident was on the left side of the bed, on his knees, with his head resting between the siderail and the mattress. The LPN told inspectors the head was trapped. He said he had to use the palm of his hand and apply force to remove it. He said the resident was face down and he was unsure whether the resident had suffocated. The resident was unresponsive. The LPN called 911 and started chest compressions.
The inspection report does not state whether the resident was resuscitated. It does not need to. The sequence of events, the 911 call, the CPR, the investigation that followed, the immediate jeopardy citation, tells the story clearly enough.
Immediate jeopardy findings carry weight precisely because they are rare and because the bar for them is high. Inspectors do not issue them for paperwork lapses or scheduling problems. They issue them when they determine that a facility's failure has caused or is likely to cause serious injury or death to a resident. At Neighborhoods Rehabilitation and Skilled Nursing B, inspectors determined that threshold had been crossed on the day they arrived.
By the time inspectors left, the facility had taken corrective action sufficient to remove the immediate jeopardy designation. The citation was downgraded to a D-level deficiency before the survey team exited the building. Inspectors noted a final revisit would be conducted to determine whether the facility had returned to substantial compliance.
The inspection report includes a note that the downgrade does not mean the facility has complied with Missouri state law, specifically Section 198.026.1 RSMo., which requires prompt remedial action on Class I violations.
What the corrective action consisted of, the inspection report does not detail. Whether the bed rails were removed from other residents' beds, whether staff were retrained, whether a new assessment process was put in place, none of that is documented in the findings available from this inspection.
What is documented is the account of LPN A standing in a resident's room, pressing his palm against a human head to pull it free from between a rail and a mattress, then beginning chest compressions on someone who was not breathing.
And the account of an assistant administrator who assessed bed rails on August 15, or possibly did not, before the resident returned from the hospital, or possibly after, with the resident in the bed, or possibly not, and who left no record of any of it because, as he told inspectors, these things are routine, and routine things are the ones he does not remember.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Neighborhoods Rehabilitation and Skilled Nursing B from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
NEIGHBORHOODS REHABILITATION AND SKILLED NURSING B in COLUMBIA, MO was cited for violations during a health inspection on September 5, 2025.
The resident had been hospitalized before the incident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.