Failure to Follow Care Plans and Resident Rights: A cognitively intact resident sustained a skin tear when a CNA rolled the resident without the required 2-person assist, another cognitively intact resident reported that a CNA grabbed the resident’s arm and pushed the resident back into the room when the resident tried to leave, and a resident with dementia was transported in a wheelchair without required leg rests, causing the resident’s foot to drag and resulting in a right ankle sprain. The facility’s investigation identified the first event as a care plan violation and documented the abuse allegation involving the second resident.
Failure to Protect Resident From Alleged Abuse: A CNA reported that another CNA used profanities toward a resident, forcibly grabbed and pushed the resident in a wheelchair, and blocked the resident with a table. The resident had dementia and moderately impaired cognition, and the care plan identified a potential for abuse and verbal or physical aggression. Although the allegation was reported to supervisory staff, the accused CNA remained assigned to the resident, and there was no documented resident assessment, MD notification, psych consult, incident report, or abuse investigation.
Verbal and Mental Abuse During Resident Care: A CNA was witnessed handling a resident roughly and screaming while providing care, with the resident and family member on the phone hearing cursing and abusive language. The resident, who had significant neurologic impairment and depended on staff for all ADLs, reported being scared, nervous, and unsafe afterward, and the record noted no documented complete nursing assessment, psych referral, or provider follow-up after the incident.
Failure to Protect a Resident from Sexual Abuse: A maintenance worker observed a visitor on top of a resident with hands under the resident’s blouse touching the resident’s breasts. The resident reported the visitor kissed them and continued after being told to stop. The resident had dementia, anxiety, schizophrenia, and encephalopathy, and later documentation noted severe insomnia. Staff assessments and the hospital exam found no visible trauma, but the event resulted in actual psychosocial harm.
A resident with dementia and severe cognitive impairment, who required staff feeding and had a history of grabbing behaviors, grabbed a CNA’s breast during lunch. Staff gave conflicting accounts of the response, with one nurse describing the CNA angrily swinging the resident’s hand away and another CNA later stating the CNA hit the resident twice. The incident records and interviews did not consistently establish whether the resident was slapped or the hand was merely redirected.
A resident with dementia, agitation, and a history of falls was placed under 1:1 supervision, but a CNA used an overbed table to block movement, then hit, pinched, and spit at the resident while the resident tried to push the table away. The resident had no behavior care plan in place before the incident, and video showed the CNA repeatedly repositioning the table and assaulting the resident while an LPN was nearby at the nurse’s station.
An LPN attempted to give pain medication to a resident with severe cognitive impairment after the resident refused by covering their mouth. The LPN removed the resident’s hand and placed the medication in the resident’s mouth, and the resident spit it out. Staff later noted a scratch and bleeding on the resident’s lower lip, but the RN supervisor and DON did not view the event as abuse.
Resident-to-resident abuse occurred when one resident unscrewed a mechanical lift handle and struck another resident in the head, causing a raised area to the scalp and an open area to a finger. Staff observed the assault, EMS and police were called, and the injured resident was sent to the ER for evaluation. The aggressor had major depressive disorder, anxiety, and moderately impaired cognition, while the injured resident had intact cognition and wheelchair use.
Failure to Follow Care Plans for Toileting and Hip Protectors A resident with dementia and fall risk was not taken to the bathroom after dinner as care planned, and was later found on the floor with an abrasion and bruise. Another resident with Alzheimer’s disease and osteoporosis did not have ordered hipsters applied, fell from a wheelchair, and later required a change to full NWB status. Staff and camera review showed the planned interventions were not carried out.
A resident with COPD requiring continuous O2, diabetes, heart failure, and a high fall risk was not given ordered evening medications, continuous oxygen, hourly safety checks, or a dinner meal over several hours. The assigned RN did not verify the resident’s whereabouts after being told the resident had a visitor, did not administer scheduled meds or ensure O2 use, and only began searching late in the shift, eventually finding the resident unresponsive on the floor beside the bed without oxygen in place. The assigned CNA did not perform ordered hourly checks, did not serve or confirm a dinner tray, and only checked the resident once more around mid-evening, despite care plans and task lists requiring close monitoring. Documentation of the incident omitted that the resident had been unaccounted for for hours, had missed medications, treatments, and a meal, and was not on oxygen when found, while leadership and the MD were not initially informed of these care gaps.
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 July 29, 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.