The Director of Nursing admitted during a November inspection that some residents had sustained bruises and skin tears from the bed rails. She couldn't remember which residents were injured or when the injuries occurred.
"She said she was not sure how long ago that was," inspectors wrote.
The facility's own policy requires risk assessments before installing bed rails and informed consent from residents or their families. Staff must evaluate alternatives first. But when inspectors toured the building at 8:45 p.m. on November 13, they found bed rails up on 28 residents who were sleeping, with no documentation showing proper assessments had been completed.
Licensed Vocational Nurse C told inspectors he had never been trained on restraint policies. He believed the facility needed doctor's orders for bed rails and thought families had to request them, but he wasn't sure about either requirement.
"He said he thinks he just had on the job training," the inspection report states.
The nurse said bed rails were used because they "decrease the risk of injury" but couldn't explain how long they stayed up or which residents needed them.
Staff gave contradictory information about basic policies. Certified Nursing Assistant A said bed rails prevent residents from falling out of bed at night. CNA B warned that bed rails "could cause residents who are cognitively impaired to feel trapped in bed."
Registered Nurse B told inspectors that "bedrails can be restraints and the facility should have doctor's order to have them installed." She explained that bed rails can hurt residents who try to climb over them.
But the facility's nurse practitioner contradicted his own staff, telling inspectors that "all beds at the facility should have bed rails on them" and that "the facility does not need a doctor order for bed rails."
The nurse practitioner admitted he had never assessed residents for bed rail use and didn't know how many residents had them. He acknowledged the risk that bed rails "could be perceived as restraints" and said that when rails surround a bed completely, "the resident would be locked in, resulting in the resident not being able to get out of bed, which would be considered a restraint."
The administrator added another layer of confusion, claiming the facility was a "restraint reduction facility" that used bed rails. He insisted they don't actually use bed rails at all, calling them "assist bars" instead.
Federal regulations treat bed rails as restraints when they prevent residents from freely exiting their beds. The devices can cause entrapment injuries when residents try to climb over them or slip between the mattress and rail. Research has documented dozens of deaths from bed rail entrapment, leading to strict requirements for their use.
Villa Toscana's written policy acknowledges these risks, requiring staff to "assess the resident for risk of entrapment from bed rails prior to installation" and to "review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent."
The policy also mandates that facilities "attempt to use appropriate alternative prior to installing a side or bed rail" and ensure "correct installation, use and maintenance of bed rails."
None of these steps appeared to have been followed for the 28 residents found with bed rails during the inspection.
The Director of Nursing told inspectors there had been injuries - bruises and skin tears - but couldn't provide specifics about which residents were hurt or when the injuries occurred. She said she didn't know of any residents who had declined due to bed rail use, but her lack of detailed knowledge about the injuries raises questions about the facility's monitoring.
The widespread use of bed rails without proper assessment or documentation suggests systemic problems with restraint policies at the 240-bed facility. Staff confusion about basic requirements indicates inadequate training on resident safety protocols.
Federal investigators classified the violation as causing minimal harm or potential for actual harm to a few residents. But the presence of 28 residents sleeping behind bed rails without proper safeguards represents a significant breakdown in care standards that could have resulted in serious injuries or deaths.
The inspection occurred in response to a complaint, suggesting someone - likely a family member or former employee - was concerned enough about conditions to contact state regulators.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Toscana At Cypress Woods from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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