The facility failed to conduct thorough investigations into two separate resident-to-resident abuse incidents involving cognitively impaired residents with dementia and behavioral issues. In one case, a CNA found a resident pinning another to a bed with hands around the neck, but the risk manager relied only on a verbal report from an LPN, did not obtain a written statement from the witnessing CNA, and misunderstood key details of the event. In the second case, two residents engaged in a physical fight with punching, pushing, and kicking after one wandered into the other’s room; the LPN reported visible facial redness that later turned purple, yet the risk manager did not secure complete staff statements, had not read the detailed nursing note describing the punching, and made assumptions about what occurred. Despite a policy requiring timely internal investigations, the facility did not fully gather or reconcile staff accounts and documentation for these alleged abuse incidents.
The deficiency concerns the facility’s failure to thoroughly investigate several abuse-related incidents. In one case, a resident sustained facial lacerations and an intracranial hemorrhage, and leadership attributed the injuries to self-inflicted contact with bed siderails without investigating a former roommate known to have aggressive behaviors, despite external concerns about that roommate’s violent history. In another incident, a staff member reported seeing a CNA pull a resident by the wheelchair arm and yell at him, but the facility deemed the allegation unsubstantiated after the reporting employee resigned and conducted no further inquiry. In a third case, a resident reported that an RN threw a clipboard at him, resulting in a hand bruise, yet the facility relied on a reported retraction and the resident’s decision not to press charges to label the allegation unsubstantiated and document “confabulation,” even though the resident later stated he had not retracted the allegation and the only written investigation was a brief statement from the Risk Manager.
A resident reported feeling verbally abused and retaliated against by an RN, and this allegation was communicated by the SSD and HRD to the Administrator, who also served as the abuse coordinator. Despite witness statements documenting knowledge of the alleged verbal abuse and information that a staff witness existed and a false witness statement had been given, the Administrator did not suspend the RN or report the allegation to state agencies in accordance with the facility’s abuse policy. The allegation was not reported to state agencies until weeks later, contrary to policy requirements for prompt reporting of abuse allegations.
A resident with chronic pain, hemiplegia, and a history of opioid abuse alleged that a CNA befriended her, obtained her bank card and PIN, and received thousands of dollars via withdrawals and mobile payments to purchase prepaid money cards, while also allegedly using those cards to buy THC gummies they consumed together. The resident reported the missing money to the prior NHA and SSD and involved her POA and police, but the facility’s investigation only confirmed money transfers and the CNA’s admission to receiving funds for prepaid cards, without probing the purpose of the cards or the alleged THC use. The CNA acknowledged that, as staff, she should not have taken money from the resident, and the medical director stated staff should not provide THC to residents, yet the prior investigation did not document the drug-use allegation or required notifications, contrary to the facility’s Abuse Prevention Program policy requiring a complete and thorough investigation of exploitation and misappropriation.
The facility failed to promptly and thoroughly investigate and report several alleged abuse and neglect incidents. One resident with multiple terminal diagnoses was left on an unsupervised smoking patio for hours without documented care and was later found unresponsive, yet leadership did not treat this as a neglect allegation or initiate an investigation at the time. Another resident with hemiplegia reported a male staff member repeatedly entering his room at dusk and touching him in a way he described as violating and demeaning, but the allegation was not reported within the required 2-hour timeframe. A third resident with hemiplegia reported that a female staff member refused to provide incontinence care or give her a call light, and a fourth resident with diabetes alleged abuse related to how medications and care were provided; in both cases, the NHA minimized the allegations, misapplied the facility’s abuse definition, and delayed or limited reporting and investigative actions.
A resident with intact cognition but multiple neurologic and mobility impairments alleged that a CNA applied pressure to her crossed forearms against the bed and wheelchair during incontinence care, resulting in painful bruising on both inner forearms. Therapy staff later observed fresh, dark purple bruises and documented that the resident linked them to aides she was upset with, while a NP skin assessment documented scattered upper-extremity bruising and a contusion, and psychiatry documented an allegation of being grabbed in an uncomfortable manner. Despite existing care plan interventions and facility policy requiring reporting, documentation, and investigation of new skin impairments and injuries of unknown origin, leadership acknowledged they were unaware of the bruising initially, did not speak with the NP who documented it, and, after interviewing staff, were unable to identify the staff member involved or determine how the bruising occurred, resulting in a failure to conduct a thorough investigation of the allegation.
A resident with severe cognitive impairment and multiple health conditions was found unresponsive and later determined by EMS and hospital staff to have been deceased for some time, exhibiting rigor mortis. Documentation and staff interviews revealed that required care was not provided during the evening shift, and there were conflicting accounts regarding the discovery and response to the resident's condition. Facility administration failed to conduct a thorough investigation, did not obtain statements from all involved staff or EMS, and delayed required reporting to the State Agency.
The facility failed to conduct a thorough investigation into the misappropriation of resident funds after discovering a significant cash shortage. Multiple residents reported missing money and unauthorized withdrawals, with no receipts to support the transactions. Staff interviews confirmed that no comprehensive review or audit was performed to determine the full extent of the loss, and residents were not properly informed or guided to check their financial statements for accuracy.
A resident with severe cognitive impairment and physical dependency was found with a significant bruise and later diagnosed with a femoral neck fracture. The facility did not document a thorough investigation, as required by policy, with missing staff statements and unwitnessed accounts of the incident. Interviews revealed that the DON and other staff could not provide written documentation or clear details about how the injury occurred.
The facility did not conduct a thorough investigation into an allegation of neglect involving a resident with a foley catheter. The NHA failed to contact the family, did not interview all relevant staff, and did not obtain necessary medical records or consult the resident's urologist. Key clinical details, such as the resident's pain complaints and the presence of wounds, were missed or unknown to the investigation team.
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