A cognitively impaired resident with a history of cerebral infarction, right-sided hemiplegia, and a documented moderate risk for wandering was able to leave a supervised front porch area without staff awareness, propel a wheelchair down the facility driveway, and cross a heavily trafficked road into an area with a steep ditch and wooded terrain. Staff interviews showed that the resident was usually outside with other residents and staff present, but on the day of the incident a CNA last saw the resident on the porch and was unsure how the resident exited unsupervised. The resident was ultimately discovered by a CNA who had been alerted by a pest control worker, by which time the resident had already crossed the roadway, demonstrating a failure to provide adequate supervision and prevent elopement for a cognitively impaired individual.
Two residents with cognitive impairment and documented fall risk experienced falls when staff did not follow established transfer and alarm orders. One resident, ordered for a total mechanical lift with two-person assist, was instead transferred by a CNA using a sit-to-stand lift after the resident stated she could stand, leading to a fall when the resident released the handles and slid to the floor. Another resident, ordered to have a bed/chair alarm checked each shift and with a care profile specifying a bed alarm, was found on the floor after an unwitnessed fall with head injury when the bed alarm was not engaged and did not sound.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with anoxic brain injury, severe cognitive impairment, and total dependence for bed mobility and toileting had repeated falls from bed during care. Staff knew the resident was high risk and that he flailed, thrashed, and could be combative, but a CNA provided care alone and did not check the care plan for the required level of assistance. The DON confirmed there was no fall review to identify the root cause and no interventions were put in place after the resident rolled off the bed.
A resident who was cognitively intact but required substantial/maximal assistance for rolling in bed, with a documented care plan specifying two-person assistance for turning and repositioning, was being provided an in-bed linen and brief change by a CNA working alone. During the process of rolling the resident and removing soiled linens, the resident rolled too far and fell from the bed despite attempts by both the resident and the CNA to prevent the fall, resulting in a proximal humeral fracture confirmed by X-ray and subsequent hospital transfer.
A resident who smoked was observed keeping cigarettes in his shirt pocket while in his room and while in a wheelchair in the hallway. The facility had no smoking assessment in the chart, stated it did not require one for tobacco users, and staff reported no in-service training on residents who smoke. The designated smoking area also lacked smoking aprons, a fire extinguisher in the immediate area, and a gate or barrier.
A resident with Parkinson’s disease, contractures, and severe dementia fell from bed while a CNA was turning and changing the resident. The resident was dependent for bed mobility and the Kardex indicated two staff were required, but the CNA was unaware of that requirement and usually provided care alone. The resident sustained a right eyebrow laceration that required ER evaluation and repair.
Improper Oxygen Storage and Missing Cautionary Signage: An oxygen concentrator and oxygen cylinder were observed stored in a resident’s room without required cautionary signage on the door. The resident had unspecified dementia, a BIMS score of 00, no physician order for oxygen therapy, and staff including an LPN, RN, and DON confirmed the equipment was present and the sign was missing.
Unsafe possession and storage of smoking materials led to an accident hazard for three smokers. A cognitively intact resident with emphysema, AFib, and ASHD was observed with cigarettes and a lighter on a bedside table and chest of drawers, and two other residents were seen with cigarettes visible while seated near the exit door to the smoking area. The DON stated residents are not supposed to keep cigarettes or lighters on their person and that smoking materials should be kept in a locked box and issued at designated smoke times, while the Administrator acknowledged residents were observed with these items.
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.
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.