The incident at Friendship Rehab and Health required multiple unsuccessful attempts to move the resident before staff realized why she appeared "stuck" in her cardiac chair. Physical therapist Employee E1 and nursing assistant Employee E2 struggled to reposition the woman while therapy assistant Employee E3 braced the wheelchair from behind.
"After multiple unsuccessful attempts at repositioning, NA Employee E2 looked under chair to find patient tied down by bed sheet - knotted tightly under chair," according to the federal inspection report. The resident was "tied around her midsection (over ribcage) and was immobile."
The nursing assistant later described the discovery: "We went to go move Resident R1 up in the chair and it seemed as if she was stuck, so we checked around the chair. we ended up finding out that the flat sheet was tied around her belly and under the chair in a knot."
Resident R1 appeared unaware of what had been done to her. Staff checked for physical and emotional harm after untying the knot and successfully repositioning her.
The facility's Director of Nursing confirmed during an August 27 interview that Friendship Rehab had failed to ensure the resident was free from abuse. The DON told inspectors the facility had identified the perpetrator and terminated the employee responsible.
This was not the first time this particular resident had experienced problems at the facility. The inspection report noted the incident was "identified for past non-compliance for Resident R1," though details of previous violations were not specified.
The discovery triggered immediate facility-wide action. On August 19, the day the incident was reported, nursing leadership conducted walking rounds on all units to check for additional restraints in use. None were found.
The facility's response expanded beyond the single case. The MDS Coordinator reviewed all active care plans on August 20 to ensure restraint use was not planned for any residents. No issues were identified during this comprehensive review.
Staff education became a priority. The Director of Nursing implemented re-education across all departments on the facility's abuse prevention policy, requiring staff to complete training before their next shift. By August 21, more than 90 percent of facility staff had completed the abuse education.
The facility's Quality Assurance and Performance Improvement committee held an emergency meeting on August 19 to address the incident. Ongoing audits for restraint use began August 21 and continued daily through August 26, covering cognitively impaired residents across the facility's units.
The audit schedule followed a systematic reduction: five units daily for one week, then three units daily for one week, followed by two units daily for two weeks. This monitoring focused specifically on ensuring cognitively impaired residents remained free from physical restraints.
During interviews on August 27, fifteen staff members including nurses, nurse aides, and therapy personnel confirmed they had received training on the facility's abuse prevention policy and restraint protocols. All verified understanding that residents must never be restrained in ways that prevent independent movement.
The physical therapist who helped discover the restraint provided additional details about the incident. "Myself and NA Employee E2 untied and repositioned patient while our therapy secretary (Therapy Assistant Employee E3) braced the wheelchair for us," the therapist reported.
The therapy assistant's account corroborated the discovery: "Walking floor for therapy appointments and stopped to help PT Employee E1 and NA Employee E2 by bracing back of cardiac chair belonging to Resident R1."
Federal inspectors found the facility had achieved compliance by August 22, just three days after the incident was discovered. The comprehensive response included policy review, staff re-education, facility-wide audits, and ongoing monitoring of vulnerable residents.
Documentation reviewed by inspectors showed the facility's abuse prevention policy required no revisions. Instead, the focus turned to ensuring all staff understood existing protocols. Education materials emphasized that "under no circumstances are residents to be restrained in a way that prevents them from moving independently."
The facility's immediate response included assessing Resident R1 for injury. No physical harm was identified, and the resident showed no signs or symptoms of pain or discomfort following the incident.
Walking rounds on August 19 confirmed no other residents were subject to similar restraints. The comprehensive care plan review the following day verified no interventions encouraging restraint use existed in any resident's documentation.
Inspectors verified the facility's corrective actions through interviews with the Director of Nursing and review of the Quality Assurance and Performance Improvement monitoring process. The systematic approach to preventing recurrence satisfied federal requirements for addressing the abuse violation.
The terminated employee's identity was not disclosed in inspection documents, nor were details about how long the resident had been restrained before discovery. The incident highlighted vulnerabilities faced by cognitively impaired residents who may be unable to report mistreatment or call for help.
Friendship Rehab's response demonstrated recognition of the severity of physical restraint use. The facility's comprehensive audit system and ongoing monitoring reflected understanding that similar incidents could occur without systematic prevention measures.
The case underscored the critical role of multiple staff members in resident safety. Had the physical therapist and nursing assistant not persisted in their repositioning attempts, or had the therapy assistant not been available to help, the resident might have remained restrained for an extended period.
Federal inspectors concluded the facility had implemented effective corrective measures and achieved compliance with abuse prevention requirements. The systematic approach to staff education, ongoing monitoring, and comprehensive policy review addressed both the immediate incident and broader prevention needs.
The resident remained unaware of her restraint, a detail that emphasized both her vulnerability and the violation of her fundamental right to freedom of movement within the nursing home setting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Friendship Rehab and Health from 2025-08-27 including all violations, facility responses, and corrective action plans.