A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
A resident with DM2, prior stroke with hemiparesis/hemiplegia, malignant brain neoplasm, impaired cognition, and total dependence for transfers was being moved from bed to wheelchair using a full-body mechanical lift with two staff. After the resident was lifted off the bed and the lift was pulled away to position the wheelchair, one staff briefly released physical contact to retrieve the wheelchair, during which the resident rolled to the side, sling loops became partially detached from the lift hooks, and the resident fell, striking the back of the head and developing two hematomas. Facility lifts had hook assemblies without mechanisms to prevent sling loops from unintentionally coming loose, and although facility policy required a "TIME OUT" safety stop to verify secure straps before moving away from the surface, the incident occurred after the lift was moved from the bed. The fall documentation lacked evidence of a completed investigation or identified root cause for the sling detachment.
Two residents at high risk for falls experienced multiple falls without the facility adequately evaluating or adjusting their fall-prevention interventions. One resident with cerebellar ataxia, autism, severe cognitive impairment, and total dependence for ADLs had repeated falls from bed and wheelchair areas, including an unwitnessed fall with injury and an uninvestigated incident where he came out of a mechanical lift sling while thrashing. Despite numerous care-plan interventions and frequent fall risk assessments, the EMR lacked evidence of systematic evaluation of intervention effectiveness. Another resident with weakness, unsteadiness, hypertension, and impaired cognition had several falls from her room and wheelchair, with incomplete follow-through on ordered monitoring (such as a 3-night sleep diary) and missing documentation of new interventions. Observation showed a CNA encouraging this resident to transfer independently during toileting and bed transfers despite her unsteadiness and repeated requests for help, contrary to her need for supervised or stand-by assist. These actions and omissions failed to ensure adequate supervision and effective fall-prevention measures for both residents.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, muscle weakness, and moderately impaired cognition, assessed as high risk for falls and dependent for transfers and toileting, experienced multiple falls in the dining room when staff did not consistently follow the fall-prevention care plan. The plan required non-slip footwear, not leaving the resident unattended in the dining room after meals, keeping the resident in a wheelchair rather than a dining chair, using an antithrust cushion with Dycem, and removing the Hoyer sling from the wheelchair after transfers. Fall investigations documented that the resident was found on the dining room floor on several occasions, including after not being offered toileting post-meal and when the lift sling had not been removed. Observations showed the resident being transported with the sling still under her and sling straps looped on wheelchair handles, while staff acknowledged the resident’s impulsivity and history of falls, demonstrating inadequate supervision and failure to implement care-planned interventions.
A resident with hemiparesis after a stroke, severely impaired cognition (BIMS 0), neuromuscular bladder dysfunction, and unsteadiness on feet required extensive assistance with ADLs and was care planned for fall risk, including having frequently used items within reach and education on call light use. During observation, the resident was found in bed yelling for help to be repositioned while both the portable and cord call lights were out of reach—one on the bedside table and the other wrapped around and caught under the bed. Staff, including a CNA, an LN, and an administrative nurse, acknowledged that at least one call light should always be within easy reach of the resident, and the facility’s falls policy required maintaining an environment free from accident hazards with adequate supervision and assistive devices, which was not met in this situation.
A resident with polyosteoarthritis, anxiety, depression, muscle weakness, and unsteadiness, who depended on staff for most ADLs and used a wheelchair, was being transferred from a bedside commode to a chair using a Hoyer lift and sling. Two CNAs adjusted the sling to clean the resident and then raised the resident in the lift; one CNA operated the lift while the other turned away to dispose of wipes and move the commode. During this time, the resident complained of back pain, moved, and slipped through the buttocks opening of the sling, striking her head and back on the floor, resulting in a head abrasion, bruising, and ongoing pain. Documentation showed that required lift and transfer evaluations were not completed until weeks after the incident, MDS assessments did not reflect mechanical lift use, and no reassessment of the resident’s transfer status or anxiety related to the lift occurred immediately after the fall, despite facility policy requiring ongoing assessment of transfer needs and proper use of mechanical lifting devices.
A resident with hemiparesis, hemiplegia, dementia, and a history of falls was care planned for multiple fall-prevention interventions, including ensuring the call light was within reach and encouraging its use, keeping the chair reclined when not eating, and providing lateral support. Despite this, staff did not consistently keep the call light within the resident’s reach, and a fall was witnessed in which the resident fell from a wheelchair and sustained skin tears. Subsequent observations found the resident reclined in a Broda chair with the call light behind the bed and out of reach, even though staff acknowledged that fall interventions are listed in care plans and that call lights should be accessible to residents, in accordance with the facility’s falls management policy.
A cognitively impaired resident with dementia, dysphagia, and upper extremity weakness, who had documented hot liquid safety interventions in place, was served a second cup of coffee in a lidded mug without staff checking the temperature. Shortly after receiving the refill, the resident spilled the coffee in the dining area, and nursing staff found redness and blistering from below the belt line to the groin and inner thighs. Post-incident measurement of the remaining coffee showed a temperature of 151°F, and hospital records documented partial-thickness scald burns to the groin and bilateral thighs after exposure to coffee measured at 157°F. Staff interviews confirmed that dietary staff were expected to check every cup of hot liquid to ensure it was below 135°F, but the dietary worker who refilled the cup could not recall taking the temperature, and another staff member acknowledged the second cup’s temperature had not been checked, leading to the resident’s burn injury.
A resident with dementia, behavioral symptoms, impaired cognition, and osteoporosis experienced multiple falls, including falls with major injury and a hip fracture requiring surgery. The facility repeatedly failed to complete root cause analyses after these falls, did not finish required dementia and falls CAAs, and delayed implementing individualized interventions such as assisted transfers, toileting schedules, frequent checks, and environmental modifications. Many fall investigations were missing or incomplete, and staff on the floor lacked access to the care plan and did not independently develop fall-prevention measures, relying instead on a CNA and an RN to determine and communicate interventions, sometimes weeks after the events.
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