A resident was transported from dialysis in a wheelchair that was not secured in the van. When the CNA lowered the lift gate and turned away, the resident rolled backward out of the van, struck his head on the ramp, and sustained head and arm injuries requiring ED evaluation. The resident had CKD stage 4 and hemiplegia, and the ED record documented head and arm contusions, a skin tear, and a small posterior head laceration.
Failure to supervise a resident near an exit door led to an unsupervised exit from the facility. The resident, who had severe cognitive impairment and hemiplegia/hemiparesis, was known to sit by the rear door with his hand on the handle, but staff did not prevent him from pushing the door open and propelling his wheelchair outside. Surveillance video confirmed he remained outside for about three minutes before being found by housekeeping.
A resident with hemiplegia, impaired cognition, and fall risk had the call light left wrapped around the overhead bed light fixture and out of reach during repeated observations. CNAs stated the call light should remain within reach except during brief room cleaning or bed making, and the Administrator said residents' call lights were expected to stay within reach at all times.
Failure to reassess a resident’s wheelchair alarm led to a deficiency when staff continued using the alarm for fall prevention without documented ongoing evaluation of its need, effectiveness, or possible reduction. The resident was cognitively intact, chairbound, and had not fallen in a long time; staff and the DON confirmed the alarm remained in place despite no documented reassessment, even though the resident’s last fall had occurred long before and quarterly fall risk reviews showed no recent falls.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, and dependence for transfers was care planned for a total lift, but staff used a sit to stand lift instead. The CNA acknowledged not following the Kardex and care plan, another CNA assisted without checking the transfer instructions, and the NP, LPN, and DON confirmed the resident could not consistently follow commands and should not have been transferred with a sit to stand lift.
Failure to Apply Required Shoulder Restraint During Van Transport: A resident with intact cognition was transported in a facility van using a wheelchair securement system and lap belt, but the shoulder restraint was not applied. The resident reported feeling unsafe and said the restraint was requested but not used. The Activities Director confirmed the omission, and the DON/Administrator acknowledged that staff were expected to follow the manufacturer’s wheelchair tie-down guidelines requiring both lap and shoulder restraints.
A resident with mild dementia and a BIMS score indicating cognitive intactness was observed vaping in the room despite a facility policy stating e-cigarettes may not be kept in resident rooms and residents must be accompanied by staff during smoking times. The resident reported keeping the vape device on hand, receiving vape supplies from family, and not being told vaping was prohibited in the room. The DON was unaware of the in-room vaping, and an oxygen concentrator was present near the resident's chair during observation.
A resident with anoxic brain damage and a persistent vegetative state fell during ADL care when a side rail was not fully secured. CNA care involved repositioning the resident while the rails were raised, but the resident slid over the left side of the bed and was found on the floor with a scalp laceration and bleeding; the RN later noted the top left rail was down and the resident had a head injury.
Failure to supervise allowed two residents with severe cognitive impairment and dementia to follow a transportation employee out the front entrance and remain outside unattended for about 11 minutes. Staff did not realize the residents had exited until a dietary aide and a family member spotted them in the parking lot and alerted the facility. The residents were ambulatory with walkers and were later brought back inside.
Failure to supervise a resident with swallowing precautions during meals. A resident with CVA, dysphagia, and severe cognitive impairment had ST recommendations for close supervision, small bites and sips, and upright posture while eating. Staff were aware of the resident’s choking risk and prior choking episode, but during lunch an LPN and CNAs stepped away and no one remained at the table with the resident. The resident began choking, required emergency intervention, was transferred to the hospital, and later died after being removed from the ventilator.
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.