Failure to Protect Residents After Allegation of Neglect: An LPN reported that an evening nurse left without giving report or counting narcotics, and no nurse was available on the unit overnight to administer medications. Residents stated they waited for bedtime meds and pain relief, were upset about not having a nurse, and some sought help on another unit. MAR review showed missed bedtime medications for multiple residents, and facility policy defined this type of failure to provide needed care as neglect.
Failure to Investigate and Report Abuse and Neglect Allegations: The facility failed to investigate, document, and report abuse/neglect allegations involving two residents. One resident with moderate cognitive impairment was allegedly verbally abused by the former Administrator in front of CNA students, but no facility investigation or State report was found. Another resident with severe cognitive impairment and total ADL dependence was allegedly neglected when care and meds were withheld, and the facility also could not produce investigation records or State reporting. Abuse education was documented after the incidents.
A facility failed to implement its abuse prevention and investigation policies when a severely cognitively impaired resident with a history of inappropriate sexual behavior sexually touched two other residents. Staff observed the resident placing his hand inside one resident's shirt and pants on more than one occasion and also observed similar sexual contact with another resident. The affected residents were cognitively impaired and one was nonverbal, and interviews confirmed there was no increase in supervision or other restrictions in place when the incidents occurred.
Failure to Protect Resident During Abuse and Neglect Allegation A resident with quadriplegia, PTSD, and total dependence on staff for care reported ongoing night-shift neglect, including call lights being turned off, delayed response to care needs, and staff refusing to provide care. She showed surveyors photos and videos of staff leaving her in bed improperly, turning off her call light, and police responding after she called for help. The DON knew police had been called and was aware of the neglect allegation, but the facility did not protect the resident from the alleged perpetrators, report the allegation, or complete a thorough investigation, and the resident remained fearful and refused to allow her door to be closed.
Failure to remove alleged perpetrators during a sexual abuse investigation. A resident alleged that two housekeeping employees made sexual comments and attempted to expose themselves, but both employees were allowed to continue working full shifts after the allegation was reported. The facility’s abuse policy required immediate protection of residents, including removal of alleged perpetrators pending the investigation, but the Administrator stated they were not suspended because the facility was still determining whether the allegation was credible.
Failure to Report Alleged Verbal Abuse Between Residents: An LPN documented a heated argument in which one resident yelled and cursed at another resident, but the incident was not reported to management or the SA as an allegation of abuse. The LPN said she separated the residents and later realized it may have been verbal abuse; the Administrator later confirmed it should have been reported and investigated.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
Facility staff failed to follow the abuse prohibition policy requiring a Virginia State Police criminal background check before employment when a Dining Server was re-hired. The HRD stated the employee had worked at the facility before, but the new background check was missed on re-hire; the only check provided was from the prior employment period.
Staff failed to implement abuse-prevention and supervision policies for a cognitively impaired, behaviorally disturbed resident who repeatedly engaged in aggressive and sexually inappropriate conduct toward other severely cognitively impaired residents on a Memory Care Unit. In separate incidents, one resident was pushed to the floor and sustained a head bump after a slap-and-push altercation, another cognitively impaired female was found in bed with the aggressive male resident while her brief was displaced and her buttocks exposed, a male resident with dementia suffered a lip laceration after being struck, and a female resident on anticoagulant therapy developed significant bruising and swelling to her eye after reporting she was hit during a struggle over a reacher/grabber. Despite facility policies requiring individualized supervision, hazard mitigation, and protection from abuse, the aggressive resident continued to ambulate freely throughout the unit with direct access to other vulnerable residents, and staff and leadership acknowledged that such resident-to-resident altercations and non-consensual bed-sharing constitute abuse.
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.