A resident with renal dialysis dependence, muscle weakness, and CVA history was being transported in a wheelchair when a driver started the van before fully securing the wheelchair securement system. While traveling uphill, the wheelchair fell backward, causing a T1 fracture and subdural hematoma. The DON initiated CPR, EMTs transported the resident to the ED, and the resident later died from anoxic brain injury after cardiac arrest.
Improper Mechanical Lift Transfer Resulted in Resident Fall: A resident with a history of right hip fracture, weakness, and unsteadiness fell during a mechanical lift transfer after two lift pads were placed under the resident. CNAs used the lift while the resident had two slings/pads under them, causing the pads to separate and the resident to fall to the floor, hit their head on the lift, and land on their right side. The resident was later sent to the ER and hospital records showed a closed right hip fracture.
A resident with moderate cognitive impairment, wheelchair dependence, and a care plan for two staff and a mechanical lift for all transfers was moved by a CNA using a one-person pivot transfer instead. The resident reported leg pain and heard a cracking sound when weight was placed on the leg, and imaging later showed an acute fracture of the thigh bone just above the knee. Interviews confirmed the CNA did not follow the resident’s care plan and performed the transfer without the required lift.
Failure to supervise a resident with severe cognitive impairment led to an elopement event when the resident held open an exit door and left the unit in a wheelchair. Staff later found the resident outside with a head knot and a scrape on the hand after the wheelchair tipped over near the ramp. The resident had dementia, was identified as an elopement risk, and staff reported prior exit-seeking behavior.
A resident with severe cognitive impairment, wandering behavior, and a known elopement risk exited through an alarmed kitchen door after staff cleared the alarm without checking the outside area. Staff later found the resident outside near another entrance and returned the resident inside. The resident had diagnoses including dementia, was care planned for wandering, and had orders and assessments documenting high risk for elopement.
Two residents were observed independently keeping cigarettes and lighters in their personal belongings during smoke breaks, despite care plans and smoking safety screens stating their smoking supplies were to be stored at the nurses’ station and that they required supervision and smoking aprons. One resident with epilepsy and glaucoma was seen with multiple lighters and a pouch containing cigarettes and a lighter, while another resident with mobility impairment, schizophrenia, bipolar disorder, and fall risk was seen removing a cigarette and lighter from a case and lighting the cigarette without staff assistance. Staff interviews confirmed residents were not supposed to have smoking paraphernalia on their person, and the APRN stated no residents had been approved for that.
A resident with ESRD, DM with CKD, dialysis dependence, and bilateral LE amputations was transported in a facility van when the wheelchair flipped backwards because the front secure straps were not attached. The CNA secured only the rear straps, then drove away and the resident fell backward in the wheelchair after the van accelerated from a stop. The resident had a bump on the forearm and reported chest and lower back discomfort.
A resident with multiple chronic conditions and dependence on staff for transfers fell during a mechanical lift transfer when staff used an oversized bariatric sling instead of the correct medium sling. The resident slid out of the sling and onto the floor, and the record and interviews showed staff knew the sling was too large but used it anyway. The DON and Administrator stated the facility had not known there were different sling sizes at the time, and the sling instructions required the correct size to be selected based on the resident's assessment.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with severe cognitive impairment, a left femur fracture, and dependence for toileting hygiene required extensive 2-person assistance for toileting per the care plan. A CNA instead changed the resident while standing in the room, and the resident lost balance and fell. Interviews showed staff were trained to use safer toileting and transfer methods, including changing residents in the bathroom with support and using another CNA or nurse when needed, but the resident’s person-centered interventions were not followed.
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 October 8, 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.