Two residents were involved in a deficiency related to supervision and wander alert safety. One resident with severe cognitive impairment and known elopement risk exited the facility unnoticed through unsecured doors and was found miles away by police. A second resident’s wander alert bracelet failed to alarm during an elevator transfer, and staff later found the bracelet battery was dead. Leadership and nursing staff stated there was no policy for door checks or for the current wander alert system.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
A facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
Failure to Obtain Ordered Urine Specimen for Suspected UTI: A resident with severe dementia, poor decision-making capacity, and frequent incontinence developed lethargy, increased confusion, urinary frequency, and strong urine odor. An NP ordered a UA with C&S to rule out UTI, but the order was not transcribed, no lab requisition was created, and no specimen was collected in the facility despite ongoing poor intake and family concern. The resident was later sent to the ED, where the urine sample was obtained by the hospital.
Failure to Verify Advance Directives Before CPR: A resident with severe cognitive impairment, Parkinson’s Disease, and a MOLST indicating DNR and comfort measures only became unresponsive. An LPN who was unfamiliar with the resident’s plan of care activated the emergency response system and started CPR without first checking the MOLST or confirming the resident’s code status, even though the HCP later stated they did not want CPR or other life-sustaining treatment.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse: The facility failed to thoroughly investigate an allegation that a CNA raped a resident during incontinence care. The resident, who had intact cognition and significant medical diagnoses, reported genital and anal touching and later said embarrassment affected how they described the event. The record lacked a written or recorded resident statement, and the facility concluded abuse did not occur based on conflicting accounts rather than documenting a comprehensive investigation of all evidence.
A facility failed to report an alleged sexual abuse incident to DOH and law enforcement within the required timeframe after a resident told an LPN they had been raped by a CNA. The resident, who had intact cognition and significant neurologic and urinary diagnoses, later described intimate care that involved pain and burning, and said they felt embarrassed and ashamed when a male NS and male officers were present. The facility also allowed the male NS to complete an assessment without another staff member present and did not provide SW involvement or psychosocial interventions despite the resident being emotionally distraught and not sleeping well.
Failure to protect a resident with severe cognitive impairment and elopement risk from window exit. The resident had a history of wandering and prior exit-seeking, was placed on a secure unit with a wander guard, and later broke a window lock, exited through a room window, and fell to a lower patio roof, sustaining multiple fractures. After hospital return, the elopement assessment and care plan were not updated for window safety, and staff said they did not routinely check room windows during hourly rounds.
A resident with severe cognitive impairment and dementia-related diagnoses became combative during care and struck a CNA, after which the CNA struck the resident in the face. Witness statements and the facility’s investigation documented that care continued despite the altercation, the resident was not reapproached or redirected, and the resident had a bloody nose. The DON stated staff were expected to use de-escalation and step out if a resident was combative.
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 August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.