Failure to Supervise a Known Elopement Risk: A resident with dementia, severely impaired cognition, and a documented wander risk exited through the front door behind visitors while staff did not notice he had left. He was later found by police walking on an interstate highway and returned to the facility uninjured. Interviews showed staff were unaware of the elopement until the resident was brought back.
Unsafe Smoking Supervision: A resident with cerebrovascular disease, quadriplegia, muscle wasting and atrophy, and diffuse traumatic brain injury was documented as unable to safely hold a cigarette, with care plan instructions stating the cigarette must be lit and held by staff. However, staff were observed lighting the cigarette and allowing the resident to hold it herself while smoking, and staff interviews confirmed this practice despite the resident being identified as an unsafe smoker.
The facility failed to complete fall risk assessments and update individualized fall prevention interventions after repeated resident falls. A resident with stroke and seizures had an unwitnessed fall with no documented fall assessment or care plan update, and two other residents with cognitive and mobility-related diagnoses had multiple falls without required reassessment or new interventions. Staff interviews confirmed the fall assessments were not completed as required and that care plans were not updated after the falls.
Unsafe smoker left unsupervised while smoking: A resident with severely impaired cognition, hemiplegia, and substance-related diagnoses was identified as needing 1:1 supervision for smoking. Staff wheeled him to the smoking patio and left him there without supervision, and he was later observed with a lit cigarette. An ADON confirmed he was smoking unsupervised, and the RN confirmed he had left the resident alone despite knowing supervision was required.
A facility failed to consistently identify and supervise unsafe smokers or control their smoking paraphernalia. One resident with TBI, Parkinson’s disease, and moderate cognitive impairment was seen smoking in another resident’s room while oxygen was in use, and later was found smoking in his room with cigarettes in his possession. Another unsafe smoker was observed holding cigarettes despite care plan interventions requiring supervision and staff control of smoking supplies. Staff interviews showed confusion about smoking status and inconsistent awareness of who was unsafe.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A severely cognitively impaired resident with dementia, a BIMS score of 3, and a documented elopement/wandering risk exited the building unsupervised after a CNA mistook him for a visitor and entered the door code. The resident, who wore a wanderguard, was later found standing beside a busy highway and resisted staff attempts to bring him back inside. Interviews and observations showed the door/wanderguard system was malfunctioning and multiple exits did not alarm or stay locked when residents approached.
A resident with dementia, severe cognitive impairment, and a documented high risk for wandering, who wore a wander guard and ambulated independently, eloped from the facility by following visitors out the front entrance while staff were unaware. Policy assigned responsibility to the charge nurse to know resident locations and required all personnel to report attempts to leave, yet no staff noticed or reported the resident’s departure after last seeing him at dinner. Video showed the resident exiting behind visitors, attempting to re-enter, then walking off toward another wing and out of view; he was later found by police walking on a nearby interstate and returned to the facility, stating he was trying to go home.
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
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.