A resident reported an unauthorized online clothing purchase charged to their funds, and the facility documented this as an allegation of exploitation/misappropriation of property. Facility policy required prompt reporting of such allegations to the Abuse Coordinator, state agency, and law enforcement. However, there was no evidence that the Sheriff’s Department was notified, and later contact with an investigator confirmed no report existed. Internal email communication also showed that police had not been to the facility, and staff did not perform a documented follow-up with law enforcement, resulting in a failure to report the alleged misappropriation as required.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
The facility failed to timely report an allegation of resident-to-resident verbal and physical abuse to the SSA. A resident with intact cognition reported that another resident threw a tray at her, got food on her, got in her face, and threatened to kill her; the resident said she did not feel safe. The other resident had documented physical and verbal behaviors toward others. The Administrator stated the incident was not reported because it was determined not to meet the definition of abuse, and only a verbal investigation was conducted with no documentation available.
Failure to Report Alleged Abuse: A resident with a BIMS score of 14 and diagnoses including chronic respiratory failure, HTN, dementia, psychotic disturbance, mood disturbance, and anxiety reported that a CNA was nasty to her during care. The resident said she wrote a letter about her concerns and gave it to a wound care nurse, but the Administrator first learned of the allegation during the entrance conference and the DON was not aware of any abuse concern involving the resident.
The facility failed to follow its abuse reporting policy by not promptly reporting an alleged resident-to-resident sexual incident to the Administrator and the SSA. A CNA observed two residents in the same bed, with one resident kissing the other on the lips, and stated she reported this to a nurse, later identified by the facility as an LPN, though this was not clearly documented. The ADON learned of the incident two days later and then informed the Administrator, who subsequently reported it to the SSA. Interviews revealed conflicting accounts about which nurse received the initial report and confirmed that the incident was not reported within the required 2-hour timeframe for alleged abuse.
Failure to timely report a resident fall with major injury: The facility did not submit a state reportable within the required 2-hour timeframe after an unwitnessed fall. The resident had intact cognition, required extensive assistance with transfers, and later complained of back and stump pain; ER x-ray showed a T12 compression/burst fracture. The DON confirmed the report was not filed because she was unaware of the fracture, and an LPN knew of the injury but did not notify her.
A resident reported that after requesting evening medications, a nurse left the room and was overheard saying, “I’m not going back in there. I may have to slap someone.” The resident called a family member, who came to the facility, questioned why police had not been notified, and later filed a police report. The resident also filed a formal grievance documenting the nurse’s statement. Despite a written policy requiring that all real or perceived abuse allegations, including verbal threats, be reported to the SSA within two hours and investigated, the facility treated the incident as a customer service issue, reassigned the nurse, and did not report the allegation to the SSA or conduct an abuse investigation, as confirmed by staff interviews.
A resident with severe cognitive impairment but intact limb function, care planned to use a wheelchair and not to have restraints, was observed early one morning by two dietary staff seated or reclined in a Broda chair near the nurses’ station, appearing unable to move arms or legs and verbally expressing distress. One dietary aide believed the resident’s wrists were secured with Velcro, while the other reported the resident’s apparent immobility to nursing staff but did not escalate the concern to administration. Later that morning, an Infection Control LPN saw the resident reclined in a Broda chair, recognized it could function as a restraint, and directed transfer to a regular wheelchair, but did not identify or report an abuse allegation at that time. The dietary staff did not report their observations to their supervisor until two days later, at which point administration was notified and the incident was reported to the State Agency, contrary to facility policy and staff expectations that all suspected abuse or restraint use be reported immediately.
A resident with significant cognitive impairment and multiple diagnoses reported that a man had touched her private area, and hospice staff observed unexplained bruises on her back and shoulders. Hospice personnel relayed the bruises and allegation to facility staff, including a CMA, LPNs, and the DON, and the resident’s family was also informed and later saw bruises that staff could not explain. Although the facility’s abuse policy required prompt reporting of such allegations and injuries to the state agency, the DON and Administrator, after consulting with a corporate representative, did not report the injury of unknown origin or the alleged sexual abuse to the State Survey Agency.
The facility failed to timely report an allegation of resident-to-resident physical abuse to the State Survey Agency (SSA) as required by its abuse reporting policy. A nurse documented that two residents were involved in an altercation in the dining room in which one resident reportedly walked up to another and began hitting him in the head, after which the aggressor was escorted back to his room and assessed for injury. The facility’s incident report and subsequent follow-up to the SSA listed an incorrect incident date, causing the allegation to be reported outside the required 2-hour window. During interview, the Administrator could not explain why the incident report was submitted late.
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