In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Maine. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes.
Top Areas of Noncompliance
There have been a handful of IJ citations in Maine in 2025, with F689 Accidents being the most frequently cited Ftag. There was also a F880 Infection Control IJ and a resident-resident sexual abuse IJ cited at F600.
Today, we’re going to do a 3-for-1 – three IJs cited at the same facility related to the same situations.
F909 Resident Bed
F689 Accidents
F700 Bedrails
These citations come from a reinspection survey, not a complaint. This IJ situation was identified as part of the routine survey process when it was identified that a resident reported to staff that he obtained a skin tear after hitting his arm on an exposed, uncovered piece of the bed frame which the mattress was not wide enough to cover. The surveyor observed that the mattress did not appear to be compatible with the bed frame, exposing several inches of bed frame on both sides of the mattress, creating multiple potential entrapment zones. The bed rail at the height of the resident’s head was found to be 10 inches, creating another entrapment zone. That’s how it all began.
Compliance Insights
The facility was put into IJ when it was identified that it had failed to identify hazards in the resident environment and implement interventions to prevent injury, including potential entrapment (F689). On interview, the Administrator stated that sometimes Environmental staff change out the mattresses at night and don’t notify anyone.
The gap between the bed rail and mattress created the potential for serious bodily injury or death (F700). On interview, the Maintenance Supervisor stated that the facility had a tool to measure bed rail gaps, but he was not aware of how to use it. He was also not aware of what the appropriate measurements were supposed to be between the bed rail and mattress.
To top it off, it was determined that the facility failed to implement an effective inspection plan of all resident bed equipment to ensure that mattresses fit the bed frames to prevent entrapment (F909). This was found to impact all residents in the facility, since all beds had quarter rails, but it was cited at a Scope/Severity of K (Pattern) versus L (Widespread). On interview, the Maintenance Supervisor stated that bed inspections had recently been completed, but he wasn’t sure what the inspection reviewed. The Administrator clarified that the bed inspections only evaluated the electrical mechanics of the resident beds – there was no evaluation of bed and mattress compatibility or identification of potential entrapment zones.
Issues related to bed rails are prone to land a facility in Immediate Jeopardy, and that’s often due to a negative outcome being reported and a complaint investigation initiated. At this facility, the surveyor initially observed the resident lying on a mattress which appeared too small for the bed. That’s when the skin tear issue was observed and the snowball was rolling down the hill.
- Anyone in the facility can report a potential safety concern related to a bed or side rail. Educate your staff so that if they see something, they say something. A mattress that is several inches too small for a bedframe would be easy to visualize.
- Ensure your Environmental staff or whoever is responsible for mattresses know the models of beds that are being used and the recommended mattresses to use with those bed frames.
- Staff need to conduct routine inspections of the bed frame, bed rails and mattresses. Ask your staff to see the result of the most recent inspection and any follow-up action that was taken. Ask if they have the right tool to measure entrapment zones and if they know how to use the tool. Based on this IJ situation, sometimes it’s better to trust, but verify.
🚨 Concerned About Compliance? Let CMSCG Help You Stay Survey-Ready
At CMS Compliance Group, we don’t just identify problems—we help you solve them. Our interdisciplinary team has a proven track record of guiding nursing homes and other post-acute providers through the most serious compliance challenges.
Want to check your facility’s survey readiness? CMSCG offers:
- Mock surveys with detailed findings across all departments, including Life Safety and Environmental – let us help you identify potential issues with bed rails before someone else does.
- Ongoing quality assurance reviews to keep your systems functioning at the highest standards
Let’s make compliance your organization’s strength. Call us at 631.692.4422 or contact our team to schedule a consultation.
