A resident with morbid obesity and bilateral foot drop, whose care plan called for two staff for bed mobility and incontinence care, slid off the edge of the bed during perineal care and sustained abrasions and skin discoloration. The resident stated an SRNA rolled them too far while the SRNA was on the opposite side of the bed, and staff interviews confirmed the SRNA performed the care alone instead of waiting for another staff member. The ADON and DON stated the resident should have had two staff assist with the care.
A resident with dementia, osteoporosis, and a right artificial hip joint, assessed as severely cognitively impaired and dependent for bed mobility, toileting, and transfers, had a care plan and Kardex requiring a two-person assist for these ADLs. An SRNA, despite knowing this requirement, began perineal care alone and rolled the resident onto her side, causing the resident to roll out of bed onto the floor. The incident report and IDT identified the root cause as failure to follow the Kardex, with contributing factors including the resident’s weakness and history of falls. An LPN and unit manager found the resident on the floor, obtained stat x-rays that revealed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where imaging confirmed a comminuted, moderately displaced femoral fracture and an ORIF procedure was performed. Staff interviews confirmed that the resident had long required a two-person assist and that only one staff member was present at the time of the incident, and also revealed that nurses and managers had not routinely spot checked SRNAs for adherence to the care plan/Kardex prior to the event.
The facility failed to provide adequate supervision and a hazard-free environment for three residents, resulting in two falls and unsafe medication handling. One resident, cognitively intact but requiring two-person assistance and supervision for toileting, was transferred to the bathroom by a single aide and left alone on the commode, where the resident was later found on the floor. Another resident with severe cognitive impairment and high fall risk, care planned for two-person transfers but without specific supervision interventions for time spent in a common area, sustained an unwitnessed fall from a chair in the TV area, resulting in facial injuries and a nasal fracture. A third resident with severe cognitive impairment, not assessed to self-administer medications, was observed with a cup of crushed medications in pudding left unattended at the bedside, contrary to facility policies requiring direct observation of medication administration and secure storage.
A resident with dementia, impaired mobility, and dependence for transfers was care planned and assigned to be transferred with a total mechanical lift, green sling, and assistance of two staff, as documented in the MDS, care plan, device assessment, and assignment sheets. Despite this, a CNA independently transferred the resident from wheelchair to bed without using the mechanical lift, during which the resident’s leg struck the iron bed frame, causing a full-thickness laceration that required hospital evaluation and suturing. Staff interviews confirmed that the resident was known to require a total lift and that assignment sheets clearly indicated the required lift, sling color, and two-person assist.
A cognitively impaired, exit-seeking resident with dementia and severe cognitive deficits, identified as a moderate elopement risk and care planned to reside on a secure memory unit with supervision and diversional activities, was placed in a room adjacent to an alarmed exit door. In the days before the incident, staff documented and observed escalating behaviors, including repeated statements about wanting to go home, pushing on exit doors, packing a suitcase, and being non-redirectable, yet at the time of the event, one LPN and two CNAs on the unit were occupied with other residents. When the exit door alarm sounded, staff briefly checked the courtyard and rooms, turned off the alarm, and returned to their tasks, while a deteriorated wooden gate in the courtyard fence allowed the resident to push through and leave the property. The resident walked to a nearby park and was found by citizens who called 911; law enforcement then notified facility staff, who had been unaware the resident had left, demonstrating a failure to provide adequate supervision and maintain secure egress controls for an identified elopement risk.
A resident with severe cognitive impairment and a history of psychiatric conditions was able to leave the facility unsupervised by exploiting a faulty lock and a gap in a poorly maintained fence. The resident, known to be at risk for elopement, was not immediately noticed missing, and facility checks of exits were incomplete and not performed on weekends. The resident was later found outside a nearby store and returned without injury.
A resident with severe physical and cognitive impairments was injured during a transfer when two SRNAs failed to extend the legs of a mechanical lift and improperly pulled on the lift pad, causing the device to tilt and strike the resident's head. The incident resulted in a laceration and required emergency medical care. Investigation confirmed the lift was functioning properly and the injury was due to staff not following established safe transfer procedures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment was not maintained to minimize risks, and supervision was insufficient to prevent incidents.
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