Failure to assess whether a mattress bolster was a restraint for a resident with dementia, anemia, and HTN. The resident’s care plan included bolsters to bed for fall risk, and staff observed the resident in bed with bilateral raised mattress edges, but the record had no assessments or ongoing evaluations of bolster use. A UM confirmed the facility did not assess the resident’s functional status to determine whether the bolster was a restraint.
A resident with a PEG tube had an abdominal binder in place to prevent pulling out the tube, and the care plan directed that it be worn loosely and checked every shift. The record showed the binder was being used as a restraint, but no physician order was found for its use until much later, and the DON confirmed the order had not existed when the restraint was initiated.
A resident with cancer, HTN, DM, PVD, and anxiety was found to have bed bolsters ordered without documentation that less restrictive measures were tried first. The resident had a BIMS score of 15, a fall history, and a facility fall event, but the record lacked documentation of additional fall interventions or a care plan for the bolsters. The NHA confirmed the restraint-related failure.
Improper Use of Physical Restraint: A resident with dementia, falls, and a fracture was found restrained in a chair with sheets that prevented standing. Staff statements indicated an NA tied sheets around the resident’s waist and chair arms to keep the resident seated and from wandering, despite no restraint order or care plan documentation.
A resident with parkinsonism, dementia, mobility impairment, and moderate cognitive impairment was observed in a Geri chair with a tray table in front of him and a side table positioned between the chair wheels, which locked him in place and prevented independent exit. Staff later confirmed he had no need for restraints and no restraint order or evaluation, and that he also needed staff help to unlock wheelchair brakes before he could self-propel.
A resident who was documented as unable to understand her rights and responsibilities was found sitting in a wheelchair at the nurses’ station with a yellow shawl wrapped around the chair and tied in a knot, effectively restraining her, and she could not explain what had occurred. The resident’s daughter reported being told that staff had tied the shawl because they were worried the resident might lean forward and fall, despite facility policy stating that fall risk alone is not a medical symptom justifying restraint use. The clinical record contained no practitioner order or assessment supporting the use of a restraint to treat a medical condition, and leadership later confirmed that the resident had been inappropriately restrained.
A resident with cerebral palsy and intact cognition was observed seated in a wheelchair with a buckle belt secured across the waist. The record showed long-term use of the belt for positioning, but the facility did not identify it as a restraint or document interdisciplinary review, a medical symptom, informed consent, least-restrictive analysis, or ongoing monitoring. The ADON, NHA, and DON stated the belt was used for fall risk and safety, and acknowledged the resident could not remove it and that it restricted movement.
A resident with dementia and a history of falls was observed lying on a mattress placed directly on the floor, reducing the sleeping surface to floor level. The care plan did not include this intervention, and the record lacked a physician order, interdisciplinary review, consent, or ongoing monitoring. The DON stated the mattress was placed on the floor to reduce falls and later acknowledged it reduced bed mobility and created a potential restraint.
A resident with severe cognitive impairment and diagnoses including osteoarthritis of the knee and intellectual disabilities was observed in a broda chair with the rear wheel locks engaged. The LPN stated the brakes were applied to keep the resident from rolling backward because the building was old and uneven, and confirmed the locks prevented movement. The resident was later observed self-propelling at the dining table, and the Regional Consultant/Acting DON could not find documentation showing the chair had been locked.
A resident with a history of stroke and hemiplegia was repeatedly observed in bed and in a wheelchair wearing an abdominal binder, a device that restricts access to the stomach area, without documented evidence of an initial restraint evaluation or ongoing restraint assessments as required by facility policy. The policy defined physical restraints as devices attached to or adjacent to the body that the resident cannot easily remove and required assessment on admission/readmission and at least quarterly. The Regional Clinical Director reported it was unknown whether the resident could remove the abdominal binder without assistance, and no documentation showed that the need for this restraint had been evaluated or reassessed.
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 August 26, 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.