A resident with seizures and epilepsy did not receive Keppra as ordered when nursing staff allowed the medication to stop without timely MD confirmation, then later discontinued the wrong duplicate order during med recap. The resident had recurrent seizures requiring hospital transfer, and the record showed the DON confirmed the stop was mistaken while the pharmacist noted abrupt Keppra discontinuation can cause withdrawal seizures.
Failure to Protect Resident from Physical Abuse by Another Resident: A bedbound resident with limited functional ability was struck on the head with an overhead table by another resident who had documented aggressive and abusive behaviors. The injured resident sustained a scalp laceration, blunt trauma, and a closed head injury, required ED treatment with staples, and later stated he was afraid when the other resident hit him. The aggressor had prior incidents of verbal aggression, threats, and spitting, and the DON stated the resident required supervision to prevent further abuse.
Food storage and kitchen equipment were found out of compliance with policy when a container of mashed potatoes was left improperly closed, a blender pitcher had a lingering odor with peeling cover and residue, a peanut butter jar lid was smeared, and the can opener and food grater had dried food residue. A torn freezer bag exposed beef patties and other items, the label was unreadable, and another blender had a chipped, calcified paddle with dried residue. Dietary staff and the DS confirmed the conditions did not meet food safety and storage standards.
Hand hygiene and glove-use practices were not followed during incontinent care for two residents. One CNA cleaned feces from a resident, doffed gloves, put on new gloves without hand hygiene, and then touched the resident and clean bed sheets while repositioning. Another CNA used the same gloves after incontinent care to reposition a resident and touch bed sheets and side rails. Both residents had severe cognitive impairment and required extensive assistance with personal care, and the IP and DON stated staff should perform hand hygiene after glove removal and before donning new gloves.
A cognitively intact resident with seizure disorder/epilepsy and chronic pain was not informed when medication changes occurred, despite staff stating residents should be educated about such changes and the care plan emphasizing resident-centered care. The resident said he felt frustrated and out of control when not told about his medications. Staff also failed to give ordered Norco for over 12 hours after it ran out, even though the nurse acknowledged it could have been given from the emergency supply; the resident reported pain at 8/10 and said the medication usually reduced it to about 4/10.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse: A resident with schizoaffective disorder and aggressive behaviors threatened and spit on another resident, but staff did not recognize the conduct as abuse, did not report it to the Ombudsman, police, or CDPH, and did not complete the required monitoring documentation. The same resident was later placed in a room with a bedbound resident and allegedly struck that resident with an overhead table, causing a head laceration and hospital transfer. The DON and an LVN stated spitting was not abuse, while the record showed the facility’s policies required abuse identification, investigation, and reporting.
Call Light Not Kept Within Reach: A resident with hemiplegia, hemiparesis, and contractures had a call light observed coiled on the contracted side of the bed and hanging toward the floor, out of reach. A CNA stated the resident could not reach it, and an RN confirmed the facility policy required the call light to be within reach and secure as needed.
Failure to notify physician of new behavioral change: A resident with dementia, Alzheimer's disease, and depression developed new pinching and grabbing behaviors, including during feeding and interactions with staff and a surveyor. The AD said this was the first time the resident had acted this way, and RN and DON both identified the behavior as a significant COC that required physician notification, but the doctor was not notified.
A resident with anxiety and depression was prescribed Buspirone for anxiety as manifested by restlessness/inability to relax, but the order did not identify the resident’s specific behaviors. Staff described the resident’s restlessness differently, the CNA did not know the signs and symptoms, and the RN noted the MAR did not reflect the resident’s anxiety level. The DON stated the documentation was not accurate because staff had different ideas of what restlessness meant, and the facility policy required psychotropic use only for a specific, diagnosed, and documented condition.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
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.