The facility failed to store food in accordance with food safety standards in multiple kitchenette and dining room refrigerators. Temperature logs showed repeated readings above the required range, including temperatures up to 57 degrees F, and the Dietary Manager confirmed there was no documentation that temperatures were rechecked on the affected days. Facility policy required refrigerators to be at or below 41 degrees F, and FDA guidance stated they should be kept at 40 degrees F or below.
A resident had an active PRN order for Lorazepam for agitation that exceeded the 14-day limit for psychotropic medications. The DON confirmed the order was over 14 days, and the PA stated there was no documented rationale for the medication in the clinical record.
Hand hygiene and EBP were not followed during resident care. An LPN administering IV cefazolin to a resident with a PICC line picked up a saline flush from the floor with an ungloved hand, changed gloves without hand hygiene, and continued IV prep and infusion tasks. In a separate event, an LNA transferred a resident with stage 3 pressure ulcers and removed linens while wearing gloves but no gown, despite EBP signage requiring both PPE items for those high-contact activities.
The facility failed to provide written bed-hold notice to two residents at the time of hospital transfer. One resident was admitted for skilled services and had multiple hospital transfers without documentation of a bed-hold notice, and another resident was sent to the hospital for evaluation without receiving the required notice. Staff confirmed the notices were not provided because the facility does not give written bed-hold notice for residents transferred to the hospital.
Activities Program Not Directed by a Qualified Professional: The facility failed to ensure the activities program was directed by a qualified professional for a census of 106 residents. The Activities Director had previously worked as the front desk receptionist and was on leave, and the Administrator stated that neither the Activities Director nor the Administrator had the qualifications required to direct the program. The Administrator was covering the role and had education in Psychology, Business, Public Administration, and Health Care, but no experience in a social, recreational, or therapeutic activities program.
Failure to document and review pharmacy DRR/MRR recommendations: multiple residents had pharmacist notes referencing comments or recommendations that were not available in the medical record, and the DON could not confirm provider review. For another resident, the pharmacist questioned a metoprolol order, but the provider only signed the review without documenting acceptance, rejection, or rationale.
Multiple medication carts contained opened meds without required opening dates or open-expiration dates. An RN and LPN confirmed expired or improperly labeled insulin pens, inhalers, eye drops, and other meds for several residents, including insulin products, Fluticasone/Salmeterol inhalers, Latanoprost eye drops, Ozempic, and Spiriva, with manufacturer instructions reviewed showing specific discard timelines after opening.
A resident was observed sitting in a scoot Broda chair with both wheel brakes locked, and an LPN stated the wheels were locked so staff could keep an eye on the resident because the resident would go all over the place if the wheels were not locked. The resident was later seen with the wheels still locked and an empty tray table in front, while moving and pushing backward in the chair. Review showed no restraint order, restraint assessment, or restraint care plan for locking the chair wheels, and the UM confirmed this.
A resident received Midodrine despite a physician order to hold the medication when SBP was over 120. MAR review showed multiple doses were given when SBP readings were above the ordered parameter, and the DON confirmed the findings during interview.
Failure to provide meal assistance and supervision: A resident with Parkinson’s disease and impaired swallowing was observed trying to eat breakfast alone in a common area while food fell into their lap and onto the floor, with no staff present to assist or supervise. The resident’s DPOA-HC reported repeatedly requesting help at meals and not seeing staff provide it, despite the care plan calling for supervision, partial/moderate assist, verbal cues, and help with eating.
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.