A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A cognitively impaired resident with dementia, altered mental status, impaired mobility, and documented elopement risk repeatedly roamed the halls and was reported by CNAs to the assigned LPN, but no enhanced supervision was implemented. Late at night, the resident accessed an alarmed dining room exit door, held it open, and exited into an unsecured outdoor area, where the resident fell and then continued on foot to a nearby hotel. The door’s egress alarm sounded, but the LPN, despite prior training on alarm response, assumed it was related to trash removal, did not immediately investigate, later silenced the alarm, briefly looked through the door, and failed to go outside or verify resident safety. The resident’s absence was only discovered during later rounds, and a search was initiated after the resident had already been found at the hotel by emergency responders, demonstrating a failure to maintain a hazard-free environment and provide adequate supervision to prevent elopement.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
A CNA transferred a resident without using the required mechanical stand-up lift or a second staff member, contrary to the care plan. After the resident fell and complained of pain, two CNAs moved the resident to a wheelchair before a nurse assessment. The resident, who had a history of falls and required two-person assist for transfers, sustained an acute femoral fracture requiring surgery. Staff interviews confirmed the care plan and post-fall protocols were not followed.
Staff failed to follow manufacturer guidelines during a mechanical lift transfer for a resident with multiple medical conditions, resulting in the lift's wheels being locked while lowering the resident. Interviews and competency reviews revealed inconsistent staff understanding of proper procedures, despite training and care plans specifying that wheels should remain unlocked during lowering.
A resident with multiple neuropsychiatric diagnoses and identified as an elopement risk was able to leave the facility unsupervised by using a door code and a key stored on the property. Staff did not realize the resident was missing until after breakfast was delivered, and the resident was later found off property and returned by a staff member. Required routine checks were not effectively carried out, leading to the resident's unsupervised exit.
A resident with severe cognitive impairment and a history of impulsiveness exited the facility through a malfunctioning secure door that had been reported as faulty by staff but not properly documented or repaired. The resident, who was not yet on an elopement care plan or electronic monitoring, was found walking in traffic by police and EMS after the facility was initially unaware of their absence. Staff interviews revealed ongoing issues with the door and inconsistent maintenance reporting, leading to the resident's unsupervised exit.
A resident with moderate cognitive impairment and a history of wandering, assessed as high risk for elopement, was inadequately supervised and left the secure unit. The resident was later found by bystanders off facility grounds, confused and with minor injuries, after staff were unable to locate them during routine rounds. Documentation and interviews indicated the resident likely exited through a door that did not close completely or by following someone out, and there was a delay in notifying the physician and administration.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained a spiral femur fracture after being improperly transferred with a mechanical lift by only one staff member, despite care plan requirements for two-person assistance. Staff interviews revealed that single-person operation of the lift occurred during short staffing, and there was confusion about proper lift procedures, including whether to lock the wheels, leading to inconsistent practices and ultimately resident harm.
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 June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account