A resident with severe dementia and repeated falls had inconsistent supervision documentation, missing 30-minute check entries, and falls that occurred while the chart showed 1:1 or frequent checks. The resident sustained multiple injuries, including a broken nose and later a patella fracture, while staff and records were unclear about when 1:1, 15-minute, or 30-minute monitoring was actually in place. A second resident with severely impaired cognition was left in bed attached to a Hoyer lift without staff present, and staff interviews confirmed the resident was unsupervised during the transfer setup.
A resident with a history of lumbar compression fracture, repeated falls, and a care plan for 2-person assist transfers sustained a severe leg laceration when a CNA assisted him alone from a recliner to a wheelchair after he refused to wait for another staff member. The resident’s foot caught behind the wheelchair wheel, the wound required 10 stitches, and the facility’s investigation confirmed the CNA did not follow the 2-assist transfer plan.
Damaged flooring was observed in multiple common areas, including the east hall leading to therapy, the southeast hall, and the dining room near the vending machines. Surveyors found cracked, missing, and buckling tiles, and staff said the flooring had been deteriorating for a long time. Residents who independently ambulated or used assistive devices used these areas, including residents who traveled to therapy, moved on the southeast hall, and accessed the vending machines.
A facility failed to maintain an effective process for labeling resident clothing and did not ensure missing laundry was returned or replaced for three residents. Laundry staff reported frequent unmarked items, daily missing-item complaints, and multiple unclaimed clothing piles, while one resident’s POAHC replaced missing pants and shirts, another resident’s missing nightgown was not found, and a third resident reported missing underwear and t-shirts and receiving other residents’ items.
Care plan not followed for pressure relieving boots. A resident with severe cognitive impairment, dementia, Wernicke's encephalopathy, and Hospice services had an order and care plan intervention for pressure relieving boots to both feet at all times. The surveyor observed the resident in bed without the boots, and an RN verified the boots were off before applying them. A UM confirmed the resident should have had the boots on at all times.
Failure to provide ordered oxygen therapy and care plan guidance for a resident with severe cognitive impairment, hospice services, and diagnoses including alcohol-induced dementia and Wernicke's encephalopathy. The resident had an order for 2 L O2 while resting in bed to prevent hypoxia and maintain O2 saturation above 90%, but was observed in bed without oxygen. RN verified the resident was not receiving O2, and the care plan did not include oxygen goals or interventions.
Incomplete Investigation of Alleged Abuse: An allegation of abuse involving a resident was not thoroughly investigated after the resident became upset during redirection near a shared fridge and struck an LPN. The FRI lacked a statement from the directly involved LPN, did not include the security guard’s involvement or statement, and omitted the ALFA’s investigation and related statements, despite police involvement and other staff accounts being collected.
A resident with DM2 had physician orders for blood sugar checks BID, later changed to before meals, but the facility documented testing only once daily or with check marks and no results for multiple days. The resident’s care plan called for blood sugar monitoring as ordered, yet the DON stated the facility had been doing the checks once daily since admission, and the resident’s HCPOA reported concern that there were no readings to review.
Failure to Report Injury of Unknown Origin: A resident with osteoporosis and a history of falls developed discoloration on the ankle, and an X-ray later showed multiple fractures. Although the facility investigated and believed the injury was most likely related to an earlier fall, it did not report the injury of unknown origin to the SA when it was discovered or after the investigation was completed.
A resident with CHF, COPD, and intact cognition was given Furosemide twice before leaving for an outside counseling appointment, despite a care plan noting urinary incontinence and mechanical-lift transfer needs. The resident reported that staff usually held the diuretic until return from the appointment, but on this occasion the medication was given before departure, leading to three incontinent episodes while out and emotional distress on return. The DON acknowledged the dose should have been held because the appointment was brief and the resident could not be toileted at the counseling office.
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.