Resident Restraint and Abuse Incident
Summary
The facility failed to ensure a resident was treated with respect and dignity, specifically regarding the use of restraints. On several occasions, a resident's wrists were tied with bed sheets to the bed rails. A Certified Nursing Assistant admitted to using these restraints to prevent the resident from removing their brief and smearing feces, which was not required to treat the resident's medical symptoms. This action was determined to be for the purposes of discipline or convenience, resulting in serious harm to the resident and was classified as Immediate Jeopardy Past Noncompliance. The resident involved had moderately impaired cognition and was at risk for victimization due to cognitive impairment. The facility's policy on physical restraints emphasized the least restrictive environment, and restraints were to be used only to protect residents' health and safety. However, there was no documented evidence that the use of hand protectors was renewed after a certain date, and the facility's investigation revealed that restraints were indeed used, and abuse occurred. Multiple staff members observed the resident being restrained but failed to report it immediately, and some staff members denied being informed about the restraint incidents. The facility's investigation included statements from various staff members and the resident's family, as well as photographic evidence provided by the family. The Director of Nursing and the Administrator were informed of the situation, and the facility's investigation concluded that the use of restraints was inappropriate and constituted abuse. The facility's policy and procedures were not followed, leading to the deficiency.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.