A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
Failure to Follow Care Plans and Resident Rights: A cognitively intact resident sustained a skin tear when a CNA rolled the resident without the required 2-person assist, another cognitively intact resident reported that a CNA grabbed the resident’s arm and pushed the resident back into the room when the resident tried to leave, and a resident with dementia was transported in a wheelchair without required leg rests, causing the resident’s foot to drag and resulting in a right ankle sprain. The facility’s investigation identified the first event as a care plan violation and documented the abuse allegation involving the second resident.
Missed Ordered Wound Treatments: A resident with a pressure ulcer did not receive ordered Santyl ointment and dry dressing care to the foot as scheduled. Records and staff statements showed the dressing was left in place, treatments were documented as completed before they were actually done, and the wound was noted to be larger with a light tan film over the wound bed.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
Failure to Protect Resident From Alleged Abuse: A CNA reported that another CNA used profanities toward a resident, forcibly grabbed and pushed the resident in a wheelchair, and blocked the resident with a table. The resident had dementia and moderately impaired cognition, and the care plan identified a potential for abuse and verbal or physical aggression. Although the allegation was reported to supervisory staff, the accused CNA remained assigned to the resident, and there was no documented resident assessment, MD notification, psych consult, incident report, or abuse investigation.
Failure to Timely Report Alleged Abuse: A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident’s movement with a dining table, and used profanities toward the resident. The allegation was reported to an LPN and RN supervisor, but the facility did not notify DOH within the required timeframe; the resident had dementia and moderately impaired cognition.
A resident with dementia, depression, and anemia had care plans for psychosocial well-being, risk of victimization/aggression, and behavior that were not reviewed or revised after allegations of verbal and physical abuse by a CNA. Staff described the CNA yelling profanities, pushing the resident back into a wheelchair, and later blocking the wheelchair with a table. The QI nurse acknowledged the plans were not updated to reflect the incident, and an RN stated they were unaware of the allegations until later staff education.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
Failure to report newly identified hip fracture after resident altercation. A resident with dementia and moderate cognitive impairment was pushed to the floor by another resident and initially sustained a humeral fracture. After returning from the hospital, staff documented worsening hip pain, an x-ray showed an acute femoral neck fracture, and the resident later underwent a hemiarthroplasty. The incident report and DOH submission included the altercation and arm fracture but did not include the hip fracture, hospitalization, or surgery; the RN mgr stated no additional incident report was completed, and the DON stated the hip fracture should have been reported to the State Survey Agency.
Failure to Investigate Resident Injury After Altercation: A resident with dementia, pulmonary fibrosis, and anxiety was pushed to the floor by another resident and sustained a humeral fracture. After returning from the hospital, the resident later developed worsening hip pain, was found to have an acute femoral neck fracture, and underwent hemiarthroplasty. The facility did not complete an incident report or a thorough investigation to determine the cause of the fracture or whether it was related to the earlier altercation.
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 July 29, 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.