A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Failure to Notify RP/MD of Change in Condition and Missed Meds A resident with dementia, aphasia, dysphagia, malnutrition, and pressure injuries had documented lethargy, decreased alertness, poor intake, pocketing of food/meds, weight loss, and worsening LFTs, but the RP was not promptly notified of the change in condition and end-of-life planning concerns. Another resident on dialysis had repeated missed scheduled doses of multiple meds, including pain, BP, anticoagulant, COPD, psych, and ESRD-related therapies, when out of the facility, and the chart did not show MD notification of the missed doses.
Stale Urine Odor in Hallway: Surveyors observed a strong stale urine odor in the 300 hallway between rooms 303-306 on multiple occasions, and the odor was still present the next day. The DOH said she was new to the facility, described the odor-control products used by housekeeping, and noted problem areas at the end of the hallway, including one resident room with urine saturation from a leaking urine collection bag. The facility policy stated the environment should be clean, sanitary, orderly, and homelike.
A resident with dementia, aphasia, dysphagia, and malnutrition had documented decline, low O2 saturation, and ongoing SOB despite oxygen and nebulizer treatments, yet remained in the facility until family chose hospital transfer; the resident was later transitioned to hospice. In a separate case, staff administered Midodrine without evidence in the eMAR of the required BP checks before the dose and one hour after, despite the physician order requiring both monitoring points.
Failure to Clean and Monitor a Pressure Injury: The facility failed to promote healing of a resident’s unstageable DTI to the right ischium. During wound care, the DON applied treatment without cleaning the wound first, despite staff and the wound physician stating that cleansing with saline or wound cleanser was appropriate. The record also lacked weekly nursing assessments documenting the wound’s location, stage, size, and description, and the facility relied on intermittent wound physician visits that were missed when the resident was at dialysis or out of the facility.
Failure to Follow Dietician Weight Monitoring and Feeding Recommendations: A resident with AD, aphasia, dysphagia, and protein-calorie malnutrition had a care plan and physician orders addressing nutrition and feeding support, but the facility did not complete the ordered weekly weights to establish a baseline after readmission. Records showed significant weight fluctuation, poor PO intake, pocketing of food and meds, and dependence on staff for feeding and fluids, while CNAs described the resident as weak, lethargic, and needing supervision, prompting, and redirection.
Failure to timely submit the final investigation report after a resident-on-resident altercation. One resident pushed another resident out of a chair and onto the floor and attempted to hit the resident with a chair while a third resident was nearby. The Administrator stated the State Agency had been notified of the initial incident, but the final investigation was not submitted within the required timeframe and she did not know the rule was based on real clock time rather than business hours.
A resident with dementia and a history of aggressive behavior was on constant observation/1:1 monitoring when he pushed another resident out of a chair and onto the floor, then attempted to strike the resident with a chair. Staff interviews and video review showed the assigned 1:1 aide observed the altercation but did not intervene quickly enough, and the resident who was pushed required hospital evaluation for a head injury.
Failure to Notify Physician of Elevated Blood Sugars: A resident with insulin-dependent DM, dementia, and other chronic conditions had multiple BG readings above ordered parameters, but staff did not document notifying the MD or NP as required by the physician orders. An LPN acknowledged she did not call anyone, and the Medical Director stated that call orders should be followed.
Failure to Protect Resident from Alleged Sexual Abuse: A resident with dementia-related diagnoses and memory impairment was involved in an alleged resident-to-resident sexual abuse incident when another resident was observed touching a female resident inappropriately. The BOM witnessed the resident leaning over the chair, with an arm around the female resident and a hand between her legs rubbing mid-thigh, after another resident alerted staff.
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.