A resident with chronic kidney disease, recent digestive surgery aftercare, and a nephrostomy tube, who required maximal assist for transfers and used a wheelchair, was being transported by a CNA-driver for follow-up care and subsequent ER evaluation. Instead of proceeding directly to the ER, the CNA-driver diverted to a personal dental appointment, parked the facility van in an unshaded area, turned the engine off, and left the resident strapped in the wheelchair in the back of the van without supervision. The van’s doors and windows were largely closed, it became very hot inside, and the resident, who remained cognitively intact, called 911 reporting she was locked in and getting warm. Police and Fire Department responders found the non-running van with only a slightly open door and one window down, noted the resident was visibly sweating, and removed her from the vehicle. The facility’s own policies prohibited leaving residents unattended in vehicles and required continuous supervision during transport, but these were not followed, resulting in a finding of neglect and Immediate Jeopardy.
The facility failed to enforce its Smoking/Vaping policy for multiple smokers, including oxygen‑dependent residents, allowing them to keep cigarettes and lighters on their person or in their rooms and to smoke inside, including while oxygen was in use. One oxygen‑dependent resident with COPD and intact cognition had a documented history of smoking in his room and bathroom despite prior staff observations and care plan interventions requiring supervised smoking. Staff, including CNAs, an RN, and the DON, were aware of repeated in‑room smoking and residents’ refusal to surrender smoking materials but generally did not confiscate supplies, relying instead on notifying management while rounding remained infrequent. This inaction culminated in an event where a resident’s nasal cannula ignited while he smoked in his room, causing second‑degree facial burns and respiratory distress, and surveyors later observed other smokers, including another oxygen‑dependent resident and a roommate of an oxygen‑dependent resident, leaving the designated smoking area and returning to oxygen‑posted rooms with cigarettes and lighters still in their possession.
Two residents were involved in a sexual abuse incident when a CNA entered a darkened room and found one resident in a wheelchair at the bedside of another, who was lying in a fetal position with her brief pulled down, while the wheelchair-bound resident had a clenched fist against her genital area and his other hand on his exposed penis. The alleged victim had dementia, a BIMS score indicating significantly impaired cognition, and a documented lack of capacity for sexual consent, with a care plan calling for cueing, reorientation, and supervision. Staff and leadership reported that the alleged perpetrator frequently visited other residents’ rooms and masturbated in his shared room, and a prior inappropriate interaction between the same two residents in the dining room had been redirected but not reported. The resident’s representative also reported multiple prior occasions of finding the male resident in the female resident’s room with the door shut and notifying staff, who stated they would separate and monitor them more closely, indicating a failure to adequately identify, assess, and monitor behaviors that could lead to resident-to-resident sexual abuse.
A resident who was cognitively intact, on hospice, and documented as full code with a tracheostomy and feeding tube was found unresponsive by a CNA, who notified the assigned RN. The RN confirmed the resident had no respirations or vital signs but did not verify code status, assumed the resident was DNR because of hospice enrollment, and did not initiate CPR or call 911, instead contacting the physician and hospice. Another RN later saw on the electronic record that the deceased resident was full code, informed the first RN, but did not report the situation to administration. The facility’s abuse/neglect policy defined neglect as failure to provide necessary services and failure to report suspected neglect, and the failure to perform CPR on a full-code resident and to report the incident was determined to be neglect and Immediate Jeopardy.
A resident with traumatic brain injury, moderate cognitive impairment, and a history of unpredictable behaviors became agitated and physically aggressive during transfer to bed. Despite the resident’s refusals and distress when a mechanical lift was brought in, two CNAs continued care. One CNA was reported to have grabbed the resident’s arm, twisted it, and forcefully slapped the same area of the forearm multiple times while laughing, after the resident kicked and hit staff. The resident later stated that nurses slapped his arm several times, and a family member reported being told that staff repeatedly tapped the resident’s arm while saying not to do that. Multiple staff, including CNAs and LPNs, observed redness and linear marks on the resident’s right forearm, and a provider note documented localized erythema with superficial linear markings consistent with a grab or excoriation-type injury. These events show that the resident was not protected from physical abuse by staff.
A resident with obesity, lymphedema, seizure history, and an intact BIMS score was care planned for 2-person assistance with bed mobility and had a prior documented fall when care was provided by a single CNA. On a later date, a CNA who normally worked in activities was reassigned to the nursing unit, did not review the care plan, and relied on a brief verbal report that did not mention the 2-person bed mobility requirement. While providing incontinent care alone, the CNA turned the resident toward the window as the resident held the side rail; the resident’s heavy legs slipped off the bed, pulling his body to the floor. Nursing notes and an LPN’s account documented that the resident’s lower body was on the floor in a twisted position while he held the side rail, after which he complained of right hip pain. Imaging confirmed an acute proximal femur fracture, and the facility’s abuse/neglect policy defined neglect to include performing 1-person assistance when 2-person assistance is care planned.
A resident with intact cognition and multiple chronic conditions had clearly documented Full Code status confirmed through advance care planning, physician notes, nursing assessments, and the care plan. In the early morning, CNAs found the resident unresponsive, without a pulse, and not breathing, and notified an LPN, who delayed while checking an oximeter, verifying code status, and sending CNAs to get additional nurses instead of calling a code blue or starting CPR. The LPN later stated she believed the resident was already dead and did not initiate compressions, and the responding RN and another LPN, summoned to "pronounce" the resident, assumed a DNR status, did not verify code status, and also did not begin CPR. No staff performed CPR before EMS arrival; EMS confirmed the resident was Full Code, questioned the lack of CPR, and then initiated resuscitation efforts, which were unsuccessful, leading surveyors to cite the facility for failing to protect the resident from neglect by not honoring the resident’s advance directive for resuscitation.
A resident on dual anticoagulant therapy experienced a fall during incontinence care and was documented by an LPN as having abrasions, bruising, redness on the back and side, a mark on the forehead, and discoloration of multiple extremities, suggesting a possible head injury. The resident’s daughter observed visible injuries, increased pain, and behavioral changes and was told that the provider had been notified, an X-ray ordered, and Tylenol given. However, the NP reported he was only informed that the resident fell from bed and had bilateral leg pain, and he was not told about the head and multiple body injuries. Later that day, another LPN documented that the resident developed nausea, vomiting, SOB, and became unresponsive, prompting EMS transfer to the hospital, where the resident subsequently died. The failure to fully assess and communicate the extent of injuries and condition changes after the fall resulted in neglect.
A resident with dementia, fall history, and skin integrity risk had a physician order for right lower extremity skin tear care every other day on the night shift. The Treatment Administration Record showed that wound care was documented as completed on multiple scheduled dates, but the DON later found the dressing still dated from an earlier application, confirming that ordered dressing changes had not been performed for eight days. Two nurses had signed for treatments that were not provided, and weekly skin checks noted non-intact, non-new skin areas without describing the wound or dressing. This resulted in missed physician-ordered wound care and falsified documentation, contrary to the facility’s policies on neglect prevention, wound treatment management, and accurate medical record documentation.
Two residents with known behavioral conflict and one with dementia and mood instability engaged in a verbal altercation in a common area that escalated when one resident kicked the other, causing a fall and shoulder injury, while no staff were present to intervene. Staff had prior knowledge of the aggressive resident’s history of verbal and physical behaviors and the pair’s past roommate conflicts, and behavior monitoring for psychotropic use lacked specific behavior descriptions. The DON later confirmed that key staff statements were not obtained and that staff could not clearly describe the behaviors previously documented, demonstrating a failure to provide adequate supervision and behavior-specific monitoring to prevent resident-to-resident abuse.
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 June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account