The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
The facility failed to conduct thorough investigations into multiple allegations of physical and sexual abuse involving several residents with cognitive impairment, psychiatric conditions, and complex medical histories. In numerous cases, police were notified and case numbers obtained, but there was no follow-up with law enforcement, no or limited interviews with other residents or staff who might have witnessed or known about the incidents, and no timely physical or psychosocial assessments of the involved residents. This pattern included resident-to-resident physical altercations, alleged sexual contact between residents, and an allegation that a CNA forcefully moved a resident, causing a head injury, as well as a complaint that an LPN attempted to force medication and struck a resident with a remote. The Manager of Quality/Risk and the Administrator acknowledged that investigations were incomplete and did not meet the facility’s own abuse policy requirements for identifying and interviewing all involved persons and thoroughly documenting investigations.
Two cognitively intact residents reported through grievances that a CNA handled them roughly during ADL care, including pushing on a shoulder while turning and being rude and rough during care. Facility records showed documentation of one resident’s pain complaint and a skin assessment, but no comprehensive, documented investigations of either abuse allegation were found. The Administrator acknowledged only interviewing the residents about the CNA’s alleged verbal and physical abuse and not completing or documenting the thorough investigations required by the facility’s abuse-reporting policy.
The facility failed to thoroughly investigate and accurately document multiple abuse allegations involving residents and staff. In several resident-to-resident and staff-to-resident incidents, forms and investigation documents omitted the time of the incident, contained conflicting times, or failed to record when the Abuse Coordinator was notified. These events involved residents with varying levels of cognitive function, including severe impairment, and one non-verbal resident with stroke and TBI. Despite the facility’s policy requiring immediate investigation and complete documentation, key timing details were missing or inconsistent across reports.
Two residents were involved in a verbal abuse incident where one resident, with moderate cognitive impairment, threatened and used foul language toward his roommate. Staff attempted to intervene and separate the residents, and a mental health evaluation was initiated for the aggressive resident. However, the Social Service Director did not follow the facility's abuse investigation policy, failed to notify authorities, and did not document or conduct a thorough investigation, resulting in a deficiency.
The facility did not conduct thorough investigations into two separate incidents: one involving a resident with intact cognition who reported missing money from her lockbox, and another involving a cognitively impaired resident who suffered an unwitnessed fall resulting in a head laceration and cervical fracture. In both cases, required interviews and documentation were incomplete or inaccurate, and the facility's own investigative procedures were not followed.
A resident with cognitive impairment and extensive care needs experienced an unwitnessed fall and was later found to have a femur fracture after being hospitalized. The facility's investigation into the injury of unknown source was incomplete, as it did not include interviews with direct care staff, the resident, the resident's representative, or other relevant individuals, and only two statements from department heads were collected. This did not meet the facility's own policy requirements for investigating such incidents.
The facility did not conduct comprehensive investigations into multiple alleged resident-to-resident abuse incidents, failing to interview all involved or potentially affected residents and staff, and not fully following its abuse prevention policy. This resulted in incomplete assessments of incidents involving both physical and verbal abuse among residents with varying cognitive abilities.
The facility did not conduct complete investigations into multiple abuse allegations, including failing to interview involved residents and witnesses as required by policy. In several cases, such as when a resident reported being hit, another alleged inappropriate physical contact, and a hospital social worker raised concerns about bruising, the facility did not document or perform thorough investigations. The Administrator confirmed these investigative steps were missed.
A resident with moderate cognitive impairment experienced an unwitnessed fall and later was found to have a femoral neck fracture. The facility did not obtain written staff statements or conduct comprehensive interviews as required by policy, and there was no documentation of the resident's pain in the medical record during the relevant period.
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