Improper Use of Furniture as a Restraint: A resident with dementia and repeated falls was observed unable to move freely in bed after another resident’s recliner and a large chair were positioned against both sides of the bed, with a dresser also blocking one side. Staff stated the items should not have been used to block the bed, and the DON and Administrator said the facility did not use restraints.
Improper Use of Physical Restraint: A resident with dementia, severe cognitive impairment, and a history of falls was found seated in a wheelchair with a bed sheet tied around the waist and secured to the chair. RN staff identified the sheet as a restraint, and CNA staff stated it was used to keep the resident from getting up and falling; later, the CNA also said it was used for dignity after incontinence. No physician order for restraint was in place, and the record did not show evaluation of the least restrictive alternative or ongoing reassessment.
Improper Use of a Hand Mitten Restraint: A resident with chronic respiratory failure, ventilator dependence with tracheostomy, Parkinsonism, seizure disorder, and severe cognitive impairment was found with a left hand mitten tied to the bed side rail. The mitten had been used to prevent decannulation due to restlessness and pulling at trach tubing, but staff and family reported it was attached to the rail, and the RN immediately released it and assessed the resident with no injury.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was repeatedly observed positioned between the elevated head and foot sections of a bed that was placed against a wall. The facility had no documentation of medical necessity, physician authorization, restraint assessment, ongoing reevaluation, or informed consent for the bed placement, while the resident’s representative, CNA, RN, and DON all described the positioning and the facility’s lack of restraint-related documentation.
Improper Use of Perimeter Mattresses and Bedside Positioning: Surveyors found two residents with perimeter mattresses being used as bed boundaries or fall-prevention devices without physician orders or consistent restraint/device reassessments. One resident with severe cognitive and physical impairment was observed on a perimeter mattress, while another resident with quadriplegia was observed on a perimeter mattress with an armchair and pillow wedged beside the bed; staff and the spouse said the setup was intended to prevent falls or provide sensory feedback.
Improper Use of Overbed Table as a Physical Restraint: A resident with vascular dementia and severe cognitive impairment was observed on video with an overbed table placed in front of the wheelchair to keep the resident from getting up. The resident repeatedly tried to move the table away, but a CNA kept repositioning it and lowered it to box the resident in, despite no documented restraint assessment or MD order. The CNA said an LPN directed one-to-one supervision because of a fall, and the DON later acknowledged the table could be viewed as a restraint.
Harness restraint not released during meals. A resident with contracture, anoxic brain damage, cerebral palsy, severe cognitive impairment, and total ADL dependence was observed in a wheelchair wearing a snug harness vest while being fed lunch. The CNA confirmed the restraint stayed secured during the meal, despite the physician order and care plan calling for release every 2 hours and during meals; the record also lacked evidence of quarterly restraint reassessment and restraint review at the care conference.
Failure to assess and release wheelchair positioning devices used as restraints: A resident with severe cognitive impairment, seizures, and legal blindness was observed in a tilt wheelchair with a seat belt and padded lap tray in place for hours, including during meals, with no documented two-hour releases or restraint reassessments. Staff said they did not know why the devices were used, had not been instructed to release them, and therapy and nursing could not locate restraint evaluations; the MD stated the devices could be considered a restraint if used all the time.
A resident with Alzheimer's disease, depression, and adult failure to thrive was observed in bed with an abdominal binder in place, but the EMR had no physician order, assessment, consent, or care plan for its use. Staff said the binder was used because the resident kept pulling out a G-tube, yet an LPN confirmed there was no order and the DON stated the facility was unaware of the binder and had no restraint policy because it was restraint-free.
A resident with severe cognitive impairment, stroke-related paralysis, and dependence for bed mobility was repeatedly observed in bed with two upper side rails raised, despite a physician order for only one half side rail as an enabler and no documented medical symptom requiring bed rails. Multiple side rail assessments were incomplete, at times noted lack of resident/family consent, yet the care plan documented two half side rails as enablers. Staff, including CNAs, an LPN, an RN, and the DON, reported using the rails to assist with turning, positioning, and transfers, acknowledged the resident could not lower the rails independently, and recognized risks such as entrapment and injury. The resident experienced unwitnessed falls from bed both before and after side rail use, while the facility failed to ensure complete assessments, accurate orders, and proper classification of the side rails as restraints when the resident could not voluntarily release them.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 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.