The facility failed to investigate and report an incident in which a cognitively impaired, hospice-enrolled resident in the memory care unit was found nude from the waist down on the bed in another cognitively impaired male resident’s room, with the door closed and the male resident fully clothed and seated on his walker. Nursing staff documented the event, assessed both residents with no injuries noted, dressed and redirected the disrobed resident, and reported the situation to supervisory staff. The ADON stated she informed the DON and the Administrator, but leadership later acknowledged they did not treat the event as a suspicion of abuse, neglect, or exploitation, viewing it instead as typical wandering and disrobing behavior. Consequently, the facility did not conduct or document a thorough abuse/neglect investigation, did not implement protective measures during an investigation, and did not submit an investigation summary to the State Survey Agency within the required timeframe.
A resident with Alzheimer’s disease, severe cognitive impairment, osteoporosis with pathological fracture, and anxiety, who required partial/moderate assistance with transfers, was the subject of an allegation that staff blew cigarette smoke toward her and her family in a designated smoking area. An Incident Investigation Worksheet showed the allegation was reported to the state, but there was no Provider Investigation Report 3613-A in the facility’s records or in the state’s TULIP system, and no evidence that a thorough investigation was completed or submitted within the required timeframe. Nursing notes only documented that the resident and family denied the incident, and interviews confirmed that no additional investigation documentation could be found, despite facility policy requiring all allegations of abuse, neglect, exploitation, or mistreatment to be thoroughly investigated and reported within five days.
A resident with dementia, schizophrenia, and anxiety, but assessed as cognitively intact on the MDS, reported that cash was missing from her purse, which she kept on a lamp beside her bed, and stated she had told the ADON and was later informed she would be reimbursed. The BOM confirmed that missing-money allegations should be investigated by the abuse coordinator and possibly reported to the state, and found no related activity in the resident trust account. The ADON reported that an LVN had relayed the resident’s allegation that $60 was stolen, that she notified the Administrator, and that such allegations should be investigated and reported. The Administrator acknowledged receiving the report, stated the resident gave inconsistent details and described the money as misplaced, and admitted she did not document or conduct an investigation or report the allegation, instead treating it only as a grievance, contrary to the facility’s abuse/misappropriation policy.
A resident with multiple comorbidities and severe cognitive impairment reported to hospital staff that she felt staff at the facility might be neglecting her due to differing political views, leading the facility’s former Executive Director to self-report the allegation to HHSC. Despite email communications indicating that an investigation report was being prepared and a request from HHSC’s Complaint and Incident division to submit that report, neither HHSC’s TULIP system nor the facility’s records contained a 3613A Provider Investigation Report or other complete written investigation. The current ED and DON could only locate emails, in-services, and resident safety surveys, and an encrypted email that could not be opened, demonstrating that the facility did not maintain evidence of a thorough investigation or timely written report as required by its Abuse Prevention Program policy.
Two residents with dementia and behavioral issues were involved in an altercation at a coffee stand where one resident verbally abused and physically struck another despite staff attempts to intervene, and later that day the aggressive resident sustained a 1 cm skin tear to his shin while being taken to his room and repeatedly alleged that a doctor/DON had banged his leg against the bed. Although the ADM, acting as abuse coordinator, stated he investigated both the resident-to-resident incident and the allegation against the DON, he relied largely on nursing notes, had no written staff statements or other documentation of a thorough investigation, concluded there had been no physical contact in the altercation despite staff accounts of pushing and hitting, and did not further investigate or report the allegation that the DON caused the injury, contrary to the facility’s abuse policy requiring investigation and reporting of all abuse allegations.
A resident with aphasia, moderate cognitive impairment, severe mental illness, and multiple ADL deficits reported to a psychologist that a family member had been touching her vaginal area under her clothing without consent. The psychologist informed the SW, who documented the allegation and notified APS and police, and the resident requested supervised visitation rather than criminal charges. The RN, SW, psychologist, ADON, and DON all acknowledged awareness of the allegation, and the facility’s abuse policy required immediate reporting of alleged abuse and submission of written investigation findings within five working days. The administrator conducted an internal investigation but, based on her belief that the conduct was not abuse, did not submit an incident report or the investigation findings to the State Survey Agency, resulting in a failure to report as required.
The facility failed to follow its abuse, neglect, and exploitation policies in three separate cases involving vulnerable residents. In one case, a dependent, cognitively impaired resident at high risk for falls was found on the floor by the DON, who did not perform a post-fall assessment, obtain VS or neuro checks, document the event, notify the MD, hospice, or family, or initiate an investigation, even though the event was unwitnessed and the resident later experienced a rapid neurological and respiratory decline and died. In a second case, a cognitively impaired resident reported a missing debit card and suspected a former roommate; although the ADON notified leadership, the Abuse Coordinator/administrator did not initiate or document any investigation into possible misappropriation, and the card was never found. In a third case, a cognitively impaired resident with bipolar disorder repeatedly complained that a roommate with dementia entered the bathroom, watched her while toileting, and once pushed aside a wheelchair she used to barricade the door; the resident called police and alleged sexual assault, staff separated the roommates, but there was no evidence of a formal abuse investigation or comprehensive assessment as required by facility policy.
A resident receiving hospice care with severe cognitive impairment, incontinence, and a history of hemorrhoids was found by a CNA to have blood on bedding and an adult brief. An LVN notified hospice, and a hospice RN alleged possible sexual assault and approved transfer to the ER for a SANE exam. The ADON and Administrator were informed of the suspected sexual abuse. A subsequent SANE exam found no evidence of sexual assault and attributed bleeding to hemorrhoids. Despite the allegation and the facility’s written policy requiring immediate investigation and reporting of all alleged abuse to the State Agency and other authorities within specified time frames, the Administrator did not report the allegation or submit an investigation report.
Two residents reported financial and property concerns that were not treated as reportable abuse-related allegations. One resident with DM2 and dementia, but intact BIMS, filed a grievance after learning her credit card had been charged for a grocery curbside order she did not make; a staff member later documented that the resident’s saved card was used in error for the staff member’s personal order. Another cognitively intact resident reported $57 missing from a locked drawer, with the key kept visibly in an unlocked drawer; a SW documented that the drawer was intact and no money was found. The DON and Administrator acknowledged that these grievances were not reported to the State Survey Agency and were not investigated as alleged violations, despite facility policies requiring prompt reporting and investigation of suspected misappropriation and theft of resident property.
Failure to Investigate and Report Alleged Exploitation: The facility did not thoroughly investigate or report an allegation that the Admin. was stealing money from a resident with bipolar disorder and dementia, whose BIMS score indicated severely impaired cognition. The resident’s family member said the Admin. admitted taking the money for business expenses, while the DON was unaware of any further investigation and the Admin., who served as the Abuse and Neglect Coordinator, said he did not report or investigate the allegation because he believed it was false.
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