Incomplete abuse investigations for resident injuries: The facility did not complete thorough I/A reviews to rule out abuse for two residents with severe cognitive and physical impairment. One resident had bruising to the cheek after returning from the ER and another episode of facial injury after pulling at trach tubing, but one event had no I/A report and the other lacked documented prevention interventions. A second resident developed a forehead bruise after leaning against a side rail, yet the investigation included only one nurse statement and no additional staff statements.
A cognitively impaired resident with severe dementia developed a new left periorbital bruise and reported being hit by an aide. The facility’s internal report identified a CNA as a suspected abuser and noted no witnesses and no earlier injury, but the documentation did not show that other residents or the CNA were interviewed, and law enforcement was not contacted. Progress notes reflected assessment, stable VS, an ordered orbital X-ray with negative results, and ongoing monitoring, while the resident exhibited combativeness and required assistance with transfers. An MD later stated they would have sent the resident to the ER for possible CT imaging due to the head injury, but the resident was not transferred. The facility’s policy required periodic refresher training on abuse/neglect recognition, yet records showed only one abuse training with no subsequent refreshers provided.
A resident with CHF, AFib, and hypertension developed hypotension, loose foul-smelling dark stools, and disorientation, with BPs in the 70s/40s and later in the 60s/30s while on 2 L O2. Nursing staff notified an ADON, who ordered STAT labs and diagnostics and stated she would contact the MD. The MD reported giving a verbal order around 9:30 AM to call 911 and send the resident to the ER, and an order audit showed an ER transfer order entered earlier than documented in the ADON’s late entry note. Staff interviews and MD statements indicated the resident remained in the facility while the ADON waited for labs and for the MD to arrive, despite the order for immediate transfer, and the resident was only sent out after the MD arrived on-site and again ordered 911 to be called; the resident later died in the hospital the same day. The DON stated she was not informed at the time, and the ADON later wrote back-dated notes and resigned. The administrator produced only an undated, generic one-page investigation summary without the resident’s name, incident date, detailed timeline, staff statements, or root cause analysis, which did not meet the facility’s own policies for thorough investigation of suspected neglect and serious reportable events.
A resident with moderate cognitive impairment reported that a CNA, described as an obese white female with brown hair and arm tattoos, punched and pulled the hair of their nonverbal roommate. The DON and SW limited the investigation to showing the reporting resident small headshot photos of three CNAs, after which no perpetrator was identified, and they did not conduct or document interviews with CNAs or other residents. The CNA who matched the description and was assigned to the alleged victim on the shift in question was neither informed of the allegation nor suspended or removed from duty, despite the facility’s abuse policy requiring immediate removal of an alleged abuser and a thorough, documented investigation.
A resident with a history of CVA, hallucinations, and moderately impaired cognition reported that a CNA placed both hands firmly on the resident’s shoulders while repositioning a wheelchair, describing the motion as a “hit” but denying pain or intent to harm and expressing not wanting further care from that CNA. Therapy staff and an OT documented the resident’s account, including that the resident felt startled and upset. The CNA denied any inappropriate touching or hitting. The facility’s investigation was limited to statements from the resident, the CNA, and the reporting therapy staff, with no interviews of other residents, additional staff on other shifts, roommates, family, or visitors, despite facility policy requiring a thorough investigation that includes these interviews.
Failure to Investigate Abuse Allegation: A cognitively impaired resident alleged that a nightshift CNA punched them, but the CNA who heard the allegation told an LPN and then did not report it further when the LPN said he did not want to get involved. The DON and LNHA were unaware of the allegation when interviewed, and no investigation had been started at that time. The resident had severe cognitive impairment and later stated they had received punches and that the incident should have been reported sooner.
Failure to Thoroughly Investigate Alleged Abuse: A cognitively intact resident reported that an LPN yelled at them, poked them in the face, and stomped on their foot after a medication request. The facility treated the complaint as a grievance instead of an abuse allegation, and the RN who received the report was not interviewed or asked for a statement. Interviews and records showed the incident was not fully investigated, while the DON and LNHA acknowledged the allegation was not reported as abuse and the IP had no training in investigations.
Incomplete Investigation of Resident Fall and Alleged Rough Handling: A resident with intact cognition and multiple medical diagnoses fell after an unanswered call bell and reported that an LPN handled them roughly while lifting them from the floor to a wheelchair. The EMR and incident report showed the resident was found on the floor, but the facility did not promptly obtain or document statements and did not fully investigate the allegation of abuse or neglect at the time of the event.
The facility failed to conduct thorough, separate investigations into two incidents involving a resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment. During incontinent care, the resident’s legs slid off the bed while the upper body remained on the bed, and later the resident developed right hand swelling and bruising that was added to the care plan. Despite facility policy requiring prompt reporting and same-day, signed witness statements with an investigation initiated by the nursing supervisor, the DON acknowledged that no separate investigation was completed for the first incident and no investigation was conducted to determine how or when the right hand injury occurred.
The facility failed to conduct and document thorough investigations into two separate incidents involving alleged abuse and injury of unknown origin. In one case, a resident with severe cognitive impairment and on anticoagulant therapy was found with a hematoma on the elbow; the facility’s 5‑day summary claimed a thorough investigation and attributed the bruise to a prior shower, but there was no documentation of resident interviews or an interview with the LPN who was notified of the injury. In the second case, a cognitively intact resident reported that a CNA grabbed her arm and forcibly removed her dress, causing pain and leading to a substantiated finding of staff‑to‑resident abuse; however, not all on‑duty staff were interviewed, and there was no documentation of interviews with the roommate or other residents, despite facility policy requiring comprehensive, documented interviews of residents, witnesses, and involved staff.
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.