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.
Water Management Program Not Updated or Implemented as Written: The facility failed to update its Water Management Program and did not implement required control measures for water outlets, closed drinking fountains, or resident humidifiers. Surveyors observed two lobby drinking fountains, learned they had been turned off and unused for months, and found empty rooms were flushed monthly instead of daily. An LPN confirmed a resident had a humidifier, and the IP stated resident humidifiers were filled with distilled water rather than the sterile water described in the program.
A resident kept a Phenylephrine HCL 1% nasal spray on the bedside table and said he/she used it every night after buying it months earlier. Staff confirmed the medication was at the bedside, but the chart showed no MD order and no assessment for self-administration. The DON confirmed the resident had not been assessed to self-administer the nasal spray.
A resident reported that a staff member was rude and condescending during a dining room incident witnessed by others, and the resident’s spouse described the staff member as standing over the resident and speaking in an aggressive, escalating tone. An LPN said the event was reported immediately to the ADON, but the ADON did not notify the administrator, and the facility’s initial report to the SSA was submitted late.
A resident’s J-tube medications were prepared and crushed before administration, then given by an RN without verifying tube placement first. The eMAR also showed medications documented under an MNA’s login even though the MNA said he or she did not administer them, and another RN stated the meds had already been crushed before being called to give them.
A resident with pressure areas to the heels and sacrum had wounds that were not staged or fully described, and the chart lacked physician orders for the documented wound treatments. Skin reviews did not document the pressure areas, and during observation staff found inconsistent dressing status and performed wound care without orders; the DON and wound care nurse confirmed the wounds had not been staged and no treatment orders were in place.
Failure to apply an ordered palmar protector occurred for a resident with decreased ROM in the right hand. The resident was observed sitting in a Broda chair with the right hand closed tightly and no palm protector in place, even though therapy and nursing communication documents directed the resident to wear the built-up palm protector during the day and remove it for meals. An LNA confirmed the device was not applied after breakfast.
Unlabeled and expired medications were found in multiple medication rooms and carts. An LPN, RN, and MNA confirmed open eye drops, an inhaler, and PPD vials without open dates or discard dates, including medications for several residents; one resident's eye drop had been discontinued and another had already stopped receiving an ophthalmic medication. A bottle of eye drops was also found past its manufacturer expiration date.
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