The facility failed to report an allegation of suspected narcotic diversion and abuse to the State Agency within the required 2-hour timeframe after it was identified during a shift-change narcotic count. Nursing staff discovered that multiple oxycodone blister cards assigned to several residents with chronic pain and serious comorbidities had been tampered with, with oxycodone tablets removed and replaced by other medications such as loratadine and OTC Vitamin B-12, and blister backs covered with paper tape. Internal documentation shows the DON and Administrator were notified shortly after the discovery, but the Administrator did not successfully complete the electronic report to the State Agency until the following day due to user error. This delay violated the facility’s Abuse, Neglect and Exploitation policy, which requires allegations involving abuse to be reported to the State Agency immediately, but no later than 2 hours after the allegation is made.
A resident with dementia, chronic pain, and significant ADL dependence allegedly had their hands slapped by a CNA during incontinent care while the resident was yelling, crying, and swinging at staff. The witnessing CNA, despite having dependent adult abuse training and recent in‑service education on abuse reporting, did not immediately report the allegation to a charge nurse or Abuse Coordinator and instead waited and discussed it with another CNA later. The Administrator was not informed until much later, and the allegation was not reported to the state survey agency within the required 2‑hour timeframe, contrary to facility policy requiring immediate reporting of all abuse allegations.
A resident with severe cognitive impairment, post-CVA deficits, dementia, aphasia, anxiety, and depression was allegedly subjected to verbal and physical abuse by an LPN in the dining area, including being told to "shut up" and being roughly pulled and escorted by the arm while calling out for food. Dietary staff witnessed the incident and recognized it as potentially abusive but did not immediately report it to supervisory staff or the Administrator, instead delaying disclosure until later that day or the following day. Although another staff member promptly reported rude verbal remarks by the LPN, the full allegation of rough handling was not brought to leadership until the next day, and the State Agency was not notified until the morning after the incident, contrary to facility policy requiring abuse allegations to be reported to the state within two hours of the allegation being made.
The facility failed to report all required abuse allegations to the State Agency, including multiple resident-to-resident altercations and a staff-to-resident abuse allegation, despite clear internal reports and witness statements. In one incident, a cognitively impaired resident with dementia and behavioral disturbances slapped two other cognitively impaired residents; several staff witnessed both altercations, but nursing leadership directed staff to document and report only one of the incidents, omitting the second from the state self-report. In a separate incident, a CNA reported that another CNA struck a cognitively impaired, resistive resident on the thigh during care; the reporting CNA described being criticized and threatened by leadership, and the DON later characterized the contact as a pat, concluded it was not abuse, and did not report it to the state. The resident’s EHR contained no documentation of this event, no assessment, no monitoring, and no provider or family notification, despite facility policy requiring that all abuse allegations, including slapping of cognitively impaired residents, be presumed to cause pain and be reported immediately to administration and the State Agency.
A resident with metabolic encephalopathy, anemia, and sepsis, care planned for risk of impaired cognition, became agitated, verbally abusive, and refused care when CNAs attempted to change him. He called 911 twice, reporting that staff were attacking him, and told an LPN he did not feel safe with two specific CNAs, whom he described in detail, while a skin assessment showed no new injuries. CNAs reported his aggressive and accusatory behavior to the nurse, and the LPN notified facility leadership, but the allegation of staff-to-resident abuse was not reported to the state hotline until many hours later, exceeding the facility policy and administrative expectation that all abuse allegations be reported to authorities within two hours.
A resident with intact cognition, multiple medical conditions, and dependence on staff for toileting requested assistance to have a bowel movement, and a CNA told the resident to defecate in an adult brief instead of assisting with a bedpan, despite a bedpan being available. A CMA overheard the exchange, later found the resident’s brief soiled, and provided care but did not report the concern until the next day. The DON and ADON interviewed the CNA, who admitted telling the resident to use the brief, and the resident confirmed being told to go in the diaper against his preference. Although facility policy required immediate reporting of abuse allegations to the Administrator and notification of the state within 2 hours of an allegation, the incident was not reported to the state agency until the following day, outside the required timeframe.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
A resident with severe cognitive impairment, dementia, polyneuropathy, and significant ADL dependence was found with marked swelling of the left hand, later confirmed by X-ray as an acute nondisplaced fracture of the middle finger. Nursing staff documented the edema, notified the physician, and obtained an X-ray, but no staff witnessed any incident causing the injury, and interviews only produced speculative explanations such as the resident twisting fingers or catching them on side rails. The facility completed only a brief, undated investigation and, despite its policy requiring all injuries of unknown origin to be reported to the state agency within 2 hours, the Administrator determined the event was not reportable, resulting in a failure to report and thoroughly investigate an injury of unknown origin.
A resident with MS and intact cognition reported that staff flipped her too hard during care, causing her head to hit a side rail and her glasses to break, and that a staff member swatted her shoulder when she held onto the rail because she felt like she was falling. She shared these concerns with a CNA and an activities assistant, who in turn relayed them to management and nursing. Documentation and staff statements showed that the resident had reported in a prior month that someone had done something to her, but the staff member who received this information did not report it, and another nurse who later learned of the allegations did not notify the DON or Administrator. The Administrator acknowledged not reporting the abuse allegation to the state agency when first aware, believing it was a medical issue, and the facility’s self-report log lacked a timely report, contrary to policy requiring immediate internal reporting and external reporting within 24 hours.
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