Failure to Timely Report Alleged Abuse: A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident’s movement with a dining table, and used profanities toward the resident. The allegation was reported to an LPN and RN supervisor, but the facility did not notify DOH within the required timeframe; the resident had dementia and moderately impaired cognition.
Failure to report newly identified hip fracture after resident altercation. A resident with dementia and moderate cognitive impairment was pushed to the floor by another resident and initially sustained a humeral fracture. After returning from the hospital, staff documented worsening hip pain, an x-ray showed an acute femoral neck fracture, and the resident later underwent a hemiarthroplasty. The incident report and DOH submission included the altercation and arm fracture but did not include the hip fracture, hospitalization, or surgery; the RN mgr stated no additional incident report was completed, and the DON stated the hip fracture should have been reported to the State Survey Agency.
Failure to Timely Report Alleged Abuse: A CNA reported witnessing another CNA use rough hands-on care with a resident, including holding the resident’s wrists, forcing the resident’s hands into the resident’s face, and bending the resident’s fingers backward while the resident yelled out. The resident had dementia, psychotic disorder, and severely impaired cognition. The allegation was not reported immediately, and another CNA who heard about it also did not report it right away; the accused aide remained working until the report reached the DON and Administrator.
Failure to timely report abuse and injury incidents: A resident with severe mobility limitations fell from bed during CNA care and sustained a femur fracture, another resident with a high fall risk walked unassisted and fell with a hip fracture, and a dependent resident was verbally abused and handled roughly during care. The facility’s records showed the first two incidents were not reported to the NYS DOH, and the abuse allegation was substantiated after staff witnessed rough handling and screaming during care.
A resident with severe cognitive impairment had an unwitnessed fall and was later found to have an acute subcapital hip fracture after initially negative x-rays of the leg, ankle, and knee. The ADON, DON, and Administrator stated the event was not reported to the State because they believed the fracture was related to the fall and not an injury of unknown origin, despite the roommate not knowing how the fall occurred.
Failure to Report Alleged Abuse and Injuries of Unknown Origin: The DON and facility records showed multiple failures to promptly and accurately report alleged abuse and injuries of unknown origin to the State survey agency. A resident with dementia reported being hit after a visitor heard screaming, but the police report timing in the facility investigation did not match the incident timing. Another resident with severe cognitive impairment had an unwitnessed fall with a head laceration requiring hospitalization and staples, and two residents were found in bed together with no incident report or State report documented.
Failure to Timely Report Alleged Abuse-Related Incidents: The facility did not report three abuse-related allegations to DOH within the required timeframe. A resident with severe cognitive impairment alleged sexual abuse, but the event was investigated and deemed unfounded without immediate state reporting. Another resident with dementia had an unwitnessed fall and later a facial fracture, and the report was not made until the injury was known. A third resident with Lewy Body dementia was found with unexplained bruising, but staff treated it as behavior-related and did not report it as an injury of unknown origin.
Failure to timely report resident-to-resident physical aggression: two residents were involved in a verbal altercation that escalated when one resident threw a cup of ice and struck the other resident. The incident was classified as physical aggression, but the DON and NYSDOH were not notified within the required timeframe. Both residents were cognitively intact; one had anxiety, bipolar disorder, and failure to thrive, and the other had psychosis, CVA, and adjustment disorder.
Failure to timely report alleged abuse: two residents made abuse allegations, but the facility did not notify the State Agency within the required 2-hour timeframe. One resident had a bruise documented on the LUE, and a CNA reported another resident's statement that someone beat them up the night before. Interviews with staff and leadership confirmed that abuse allegations must be reported immediately and to DOH within 2 hours.
A resident with COPD, diabetes, and heart failure on continuous O2 was reported to have a visitor in the late afternoon, but an RN did not check on the resident for several hours and later could not locate the resident for medication administration. The resident was subsequently found on the floor unresponsive, with no pulse or respirations, and was pronounced deceased by EMS. Documentation showed no record that the resident was missing for several hours, no notification of the nursing supervisor or MD, and no documentation of dinner, hourly safety checks, or medication administration during that time. An internal investigation concluded the event was a medical incident and found no cause to believe abuse, mistreatment, or neglect had occurred, and the allegation was not reported to the State agency, despite facility policy requiring timely reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment.
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.