Neighborhoods Rehab: Resident Dies Trapped in Bed Rail - MO
The resident had been alone for hours.
Federal inspectors cited Neighborhoods Rehabilitation and Skilled Nursing B at 3003 Falling Leaf Court for an immediate jeopardy violation following the incident, the most serious level of deficiency CMS issues, reserved for situations where the failure has caused or is likely to cause serious injury or death.
CNA B, the nursing aide assigned to check on residents every two hours that night, said he last laid eyes on the resident around 10 or 11 p.m. He thought LPN C, the nurse who had started the resident on an IV antibiotic called Cefazolin Sodium around 10:30 p.m., would return to the room to disconnect the medication when it finished. LPN C was supposed to do exactly that. The antibiotic should have been removed at 11 p.m.
LPN C forgot.
CNA B walked into the room around 3:10 a.m. and found the IV pole hanging across the bed. The resident was on his knees on the floor beside the left side of the bed, left cheek against the mattress, right cheek pressed against the bed rail. He was not moving.
LPN C was gone from the unit. CNA B ran to the next unit and found LPN A, who called 911 and started CPR.
LPN A told inspectors that when she entered the room, the resident was on the floor on his knees, head resting between the siderail and the mattress. She had to forcefully remove his head with the palm of her hand. She said she was unsure whether the resident had suffocated, but he was face down and unresponsive when she found him.
LPN C told inspectors he had last seen the resident at 10:30 p.m. when he started the IV. He said he forgot to go back. He acknowledged that CNA B was responsible for two-hour rounds, and that CNA B and LPN A had told him afterward what they found.
The Director of Nursing said both staff members bore responsibility. CNA B, she said, assumed the nurse would check on the resident when he came back to pull the IV. The nurse never came back. "Both CNA B and LPN C should have checked on the resident sooner," the Director of Nursing told inspectors.
The standard at the facility, the Director of Nursing confirmed, is to check residents every two hours or as needed.
Between 10:30 p.m. and 3:10 a.m., a span of more than four hours, no staff member laid eyes on this resident.
What the inspection report does not resolve is what happened in the hours between when the IV finished and when CNA B walked in. The antibiotic was supposed to come down at 11 p.m. The IV pole was still hanging across the bed at 3:10 a.m. At some point in those four-plus hours, the resident went from lying in bed to kneeling on the floor with his head wedged between the rail and the mattress, unable to get free.
Nobody came.
The deficiency was cited under F0689, which covers the obligation to protect residents from accidents the facility could reasonably prevent. Inspectors classified it as immediate jeopardy, affecting a small number of residents.
The resident was found unresponsive. CPR was initiated. The inspection report does not say whether the resident survived.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 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 alone for hours.
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.