BRITTON, SD — Federal health inspectors identified four deficiencies at Wheatcrest Hills Healthcare Center during a standard health inspection completed on December 4, 2025, including a violation related to the facility's failure to follow required bed rail safety protocols.
Bed Rail Protocols Not Followed
The inspection found that Wheatcrest Hills did not meet federal requirements under regulatory tag F0700, which governs the safe use of bed rails in nursing facilities. Federal regulations require facilities to exhaust alternative approaches before resorting to bed rail use. When a bed rail is determined to be necessary, a specific four-step protocol must be followed: conducting an individualized safety risk assessment, reviewing risks and benefits with the resident or their representative, obtaining informed consent, and ensuring proper installation and maintenance.
The deficiency was classified at Scope/Severity Level D, meaning it was an isolated incident where no actual harm occurred but carried the potential for more than minimal harm to residents. While this represents the lower end of the federal severity scale, bed rail safety violations carry significant medical implications that warrant attention.
Why Bed Rail Safety Standards Exist
Bed rails are classified as potential restraint devices under federal nursing home regulations. The Consumer Product Safety Commission and the FDA have documented hundreds of deaths associated with bed rail entrapment over the past two decades. Entrapment occurs when a resident becomes wedged between the mattress and the rail, between rail bars, or between the rail and the headboard or footboard. Older adults with conditions such as dementia, agitation, or involuntary movement are particularly vulnerable.
The risk is not theoretical. Bed rail entrapment can result in asphyxiation within minutes, making it one of the more time-sensitive hazards in long-term care settings. This is precisely why federal regulations mandate that facilities first attempt alternatives — such as low beds, floor mats, bolster cushions, or motion sensor alarms — before installing bed rails.
When alternatives are insufficient and a bed rail is deemed necessary, the required safety assessment evaluates factors including the resident's body size relative to the rail gaps, cognitive status, mobility level, and history of attempting to climb over rails. Skipping or inadequately performing this assessment can leave residents exposed to entrapment risks that could have been identified and mitigated.
Informed Consent Requirements
The federal standard also requires that facilities discuss both the benefits and risks of bed rail use with residents or their designated representatives before installation. This informed consent process is not merely a paperwork exercise. It ensures that residents and families understand that while bed rails may prevent falls from bed, they introduce a separate category of risk. A resident or family member who is fully informed may choose an alternative approach they were not previously aware of.
Proper documentation of this consent process protects both the resident and the facility, creating a record that the decision was made collaboratively and with full knowledge of potential consequences.
Installation and Maintenance Standards
Even when properly assessed and consented, bed rails must be correctly installed and regularly maintained. Rails that are incompatible with a specific mattress or bed frame can create dangerous gaps. Routine checks must verify that rails remain secure, that gap dimensions stay within safe limits, and that the equipment has not been damaged or loosened through daily use.
Facility Response and Broader Context
The violation at Wheatcrest Hills was one of four deficiencies identified during the December 2025 inspection. The facility submitted a plan of correction and reported that the issue was addressed by December 6, 2025, two days after the inspection concluded.
A Level D classification indicates that inspectors found this to be an isolated occurrence rather than a systemic problem. However, the citation signals that at least one instance of bed rail use did not follow the full required protocol, creating a gap in resident safety protections.
Nursing facilities that receive deficiency citations are required to submit corrective action plans to their state survey agency and may be subject to follow-up inspections to verify compliance. Repeated violations or more severe findings can result in escalating enforcement actions, including civil monetary penalties.
The full inspection report for Wheatcrest Hills Healthcare Center is available through the Centers for Medicare & Medicaid Services and provides additional details on all four deficiencies identified during the survey.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wheatcrest Hills Healthcare Center from 2025-12-04 including all violations, facility responses, and corrective action plans.
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