Failure to protect a resident from abuse by another resident. A CNA observed one resident hit another resident in the face with a closed fist, and the injured resident had facial redness and an abrasion near the eye. The injured resident had severe cognitive impairment, dementia, depression, psychotic disorder, and wandering behaviors, while the other resident had moderate cognitive impairment, severe depression, schizophrenia, and a history of TBI. Staff interviews confirmed the injured resident was scared, skittish, and afraid for safety after the incident.
Failure to Provide Individualized Activity Programming: Three residents with dementia or other significant cognitive impairment had documented activity preferences, but staff did not consistently provide or reapproach activities to match those interests. One resident was observed in-room for long periods without activities being offered, another had limited activity participation despite stated preferences for reading, news, and outdoor time, and a third had no evidence of activity participation and the resident representative reported no invitations to activities. COTA input confirmed the facility lacked an activity director and did not facilitate independent activities for some residents.
Insulin pens in a rehab cart were found without open dates or with open dates beyond the 28-day use period. An RN confirmed the pens were available for resident use, and the DON stated staff were expected to date insulin when it was removed from the refrigerator and discard it when expired. Facility policy required insulin to be dated when first used.
Failure to maintain resident dignity during incomplete incontinence care. A resident with severe cognitive impairment, CVA, depression, BPH, total assist needs for toileting, dressing, and personal hygiene, and total bowel and bladder incontinence was observed in bed with pants down, a used brief under the legs, perineal area exposed, brown substance on the thigh, and the privacy curtain open while the roommate was present. RN stated it appeared care had been started and not finished, and CNA reported leaving the resident exposed for a skin check because the peri area was bleeding and hurting.
A resident was transferred to the hospital for evaluation, and the resident's representative was verbally notified of the transfer and bed-hold, but there was no evidence that written notice was provided. The representative stated the facility did not notify her of changes such as hospital transfers, new medication orders, or health status changes, and the DON confirmed the lack of written documentation.
Failure to Complete Significant Change MDS Assessment: A resident with dementia, progressive neurological conditions, and seizure disorder had an admission MDS that coded no mobility device use and independence with ADLs, but later was observed ambulating with a walker and gait belt. Quarterly MDSs still did not code walker use and showed increased ADL assistance needs, yet no comprehensive or significant change MDS had been completed. MDS coordinators said they were unaware of the walker use, believed the resident likely should not have been coded as independent, and confirmed the significant change MDS was missed.
Missing Anticoagulant Care Plan: A resident with intact cognition, hemiplegia, stroke, and a hx of venous thrombosis/embolism was receiving apixaban and had bruising noted on both arms after a hospital stay. Although the MAR/orders included q-shift anticoagulant side effect monitoring, the care plan did not include anticoagulant use or related interventions, and the DON confirmed the facility did not have an anticoagulant care plan in place.
A resident with severe cognitive impairment, bilateral extremity impairment, and total dependence for several ADLs was found in bed with pants down, a used brief under the legs, brown substance on the thigh, and the perineal area exposed while a lift sling remained in place. RN staff noted it appeared care had been started and not finished, and a CNA said the resident had been left exposed for a skin check because the peri area was bleeding and hurting. The DON stated staff were expected to check residents every 2 to 3 hours and complete care.
Failure to provide ordered tracheostomy care for a resident with a trach, pneumonia, chronic lung disease, and respiratory failure. Staff did not consistently change the disposable inner cannula as ordered, with records showing multiple missed or undocumented changes and notes that the cannula was not available. The resident reported staff were out of inner cannulas and sometimes removed, inspected, and reinstalled the cannula instead of changing it. RN and DON interviews confirmed supply shortages and that staff sometimes cleaned and reused the cannula without a physician order.
Failure to provide behavioral health services for a resident with schizophrenia and moderate cognitive impairment. The resident was receiving multiple antipsychotic meds and had a care plan for agitation, anger, cursing, grabbing, hitting, and kicking. The resident struck another resident, sending both to the ED. A PASRR Level II review recommended case management and a neurocognitive eval, but the record showed no evidence these services were provided.
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.