The facility failed to maintain sufficient nursing staff to meet resident needs and its own staffing plan. PBJ data showed repeated low weekend staffing, and review of staffing postings, assignment sheets, and punch-in records found frequent call-offs and staff leaving early, resulting in staffing levels that often did not match the facility assessment. Staff interviews described CNA/LNA shortages on every shift, especially weekends, and residents reported concerns that there were not enough CNAs to assist with meals and other needs. The DON acknowledged higher turnover and that staffing depended on census and acuity.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
Failure to follow abuse policy after a resident-on-resident assault. A resident with dementia and physically aggressive behaviors scratched another resident’s face, causing superficial marks to the chin and cheek. The injured resident had significant cognitive impairment and later reported that the other resident ran fingernails across her face. Staff confirmed the incident was abuse, but the clinical record contained inconsistent documentation and the behavior note did not include details of the assault.
A resident with dysphagia, esophageal obstruction, AFib, and other cardiac diagnoses had apixaban ordered by mouth BID, but the MAR documented the drug as U-SA for 17 administrations even though the record had no self-administration assessment, order, or care plan. An LPN, RN MDS Coordinator, DOR, and DON all stated that self-administration required those elements and that they were not present in the chart; facility policy also required IDT and physician determination that self-administration was safe and appropriate.
A resident with dementia, schizoaffective disorder, and a history of verbal and physical aggression was involved in a care encounter with two CNAs when he struck one CNA and the other blocked him. During the interaction, the second CNA used insulting and profane language toward the resident, including calling him a “sissy” and “fucking pussy,” while staff later described the exchange as de-escalation and the facility concluded the abuse allegation was not verified.
Failure to Follow Behavioral Care Plan During Transfer and Personal Care: A resident with dementia and psychiatric diagnoses became verbally and physically aggressive during a sling transfer and personal care. The care plan called for paired care, calm and non-threatening approaches, reduced stimulation, simple choices, reassurance, and space when safe, but staff instead engaged in a back-and-forth interaction, used rough handling, and one CNA made a joking remark to the resident during the episode.
Delayed Access to Personal Belongings: A resident with multiple chronic conditions and mobility limitations was readmitted after a hospital stay, but her personal items were left in bags behind her door and she could not access them for an extended period. She reported missing items, including her phone and charger, and said she had asked multiple CNAs for help unpacking without success. Staff said belongings were usually bagged by housekeeping and should be returned and unpacked within a day or a few days, but the record review showed no inventory reconciliation when the resident left or returned.
Neglect Related to Hydration and Access to Fluids: A resident with severe cognitive impairment and multiple chronic conditions, including ESRD on dialysis, had no fluid restriction but was found with dry, chapped lips, no water pitcher or glass in the room, and a bedside table positioned out of reach. The resident stated she was thirsty and had to use the call light to request water, while the CNA POC showed several "not applicable" fluid entries on days the resident was not out of the facility and several days with low documented intake. Staff and the DON confirmed that water should be available in the room and that neglect includes failure to provide water and basic needs.
A resident with Type 2 DM, CHF, and HTN was re-admitted after hospitalization, but the July care plan omitted diabetes and had no active goals or interventions for blood glucose monitoring or hypoglycemia. Staff notes documented lethargy, hypotension, confusion, weakness, and poor oral intake, and the NP ordered BG checks before meals and at bedtime, but no active BG monitoring orders or care plan documentation were found. The resident later had a BG of 34 mg/dL and was transferred emergently to the hospital after becoming hypotensive, bradycardic, and desaturating.
A resident with Type 2 DM was readmitted without active BG monitoring orders, insulin, oral hypoglycemics, glucagon, or a diabetes care plan. Staff documented only one fingerstick during the stay, which showed critically low BG, and the resident later became hypotensive, bradycardic, and severely hypoxic before being transferred to the hospital. Interviews with the CNA, LPN, RN, and DON confirmed the resident’s diabetes was not being monitored as expected and that the NP’s directive for BG checks before meals and at bedtime was not implemented.
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.