Those assessments, called MDS assessments, are the foundation of care in a nursing home.
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The resident had been admitted on November 8, 2025.
Quality Life Services Westmont received that citation following a February 20, 2025 inspection.
The nurse, LPN #230, told inspectors he signed off without verifying the care was actually done and acknowledged that was not proper protocol.
The administrator, standing next to the lift at 10:37 that morning, confirmed the buckle was broken and could not be fastened.
That omission sits at the center of a complaint inspection completed May 26, 2026, at Broadway Manor Care Center, a skilled nursing facility in Glendale.
The care plan coordinator at Bria of Elmwood Park, identified in inspection records as V14, walked surveyors through the gaps herself.
A resident who fell, who became ill, who needed any help at all, would have had no way to signal staff from those rooms.
Both are formulated specifically to dissolve slowly inside the body.
The inspection took place on May 27, 2026.
The inspection that surfaced the problem was triggered by a complaint and conducted on May 27, 2026.
He was cognitively intact, a BIMS score of 13 confirmed that, which meant he was capable of thinking through how to get out.