A resident with moderate cognitive impairment and an identified elopement risk wandered, became agitated, and stated a desire to leave the facility. Staff attempted redirection, but the resident exited through an improperly latching perimeter door and was found about one block away on a main road after being missing for about 10 minutes. Observations also showed staff passing through the back fence gate without entering a code, and the maintenance director acknowledged the gate was not always locked.
A resident with dementia and dysphagia required 1:1 meal supervision per the care plan, but an aide left the resident alone in the room with a meal tray while assisting another resident. The resident was later found coughing and choking, and staff had to help clear the airway. The resident also had moderate cognitive impairment and limited alertness with a need for verbal cues to take small bites.
Elopement Device Functionality Not Verified: A resident with dementia and severe cognitive impairment was identified as at risk for elopement and had a Wander Guard ordered with instructions to monitor placement every shift. However, there was no documented evidence the device was regularly checked for functionality. Staff stated they were verifying whether the device was in place, but functionality checks were not part of the facility protocol and were not clearly documented.
A resident with lung cancer and dysphagia was found to be eating without the distant supervision recommended by SLP. The resident’s care plan did not reflect the supervision need, and staff interviews showed inconsistent understanding of what distant supervision meant, with the DNS stating the resident received the correct diet but was not supervised.
Failure to follow a resident’s care plan for transport and mobility led to a fall during a dental appointment. The resident had stroke, dementia, and severe cognitive impairment, and the care plan required one-person assist in a wheelchair and use of a tilt-back wheelchair or stretcher for all transportation. Instead, the resident was taken to the appointment in a standard wheelchair, slid out onto the floor, and was sent to the ER; the RNCM confirmed the appropriate mobility device and transport services were not arranged.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
Aspiration precautions were not followed for two residents with swallowing and aspiration risk concerns. One resident with dysphagia and confusion had conflicting aspiration instructions, and fluids were left within reach at the bedside despite 1:1 supervision being documented. Another resident with pneumonia and moderate cognitive impairment was ordered for 1:1 supervision for all eating and drinking, yet cups of juice and water were observed within reach in the room, and staff gave inconsistent awareness of the supervision and bedside fluid restrictions.
A resident with DM, a foot ulcer, and chronic pain was sent for foot surgery and received post-anesthesia instructions not to stay alone and to have a responsible person present. Staff accompanied the resident to the appointment, but the CNA was later picked up and no staff member waited to assist the resident back to the facility after surgery; the resident, CNA, SS coordinator, and Admin all confirmed the resident returned without staff escort.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised off the facility premises in a busy street area after staff were told not to assist the resident back, and the resident was later found lost by police. The facility also failed to update care plans for two other residents with repeated elopement and fall events, including a resident who repeatedly tried to go to the bank and later fell from a wheelchair, and another resident with severe cognitive impairment who fell after being left alone during a fire drill.
A resident with dysphagia and aspiration precautions was given a meat sandwich without staff checking the current diet order, and the resident choked until a nearby employee performed the Heimlich maneuver. Another resident with stroke-related swallowing issues and a no-straw precaution was observed with a straw in a juice cup despite staff recognizing the resident was an aspiration risk. The incidents involved failure to follow ordered diet texture and aspiration precautions, including supervision and no-straw restrictions.
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.