A resident with dementia, behavioral disturbances, and dependence for most ADLs sustained an unexplained right elbow dislocation with fracture. Staff noted the elbow was swollen, red, warm, and painful, and the resident was sent out for hospital care, but the injury source was not identified. Review showed no documented care plan for the resident’s combative behaviors or the elbow injury, and the DON, MDS coordinator, and administrator confirmed those plans were absent.
Pain medication was not available for two residents, one resident’s morphine order was not received by the pharmacy and the first dose was delayed for more than a day after admission, and another resident missed several days of Lidocaine patch therapy because the facility ran out of stock. The second resident also had a physician order without a dose listed and a pain CAA that was not carried into the care plan. The resident reported increased back pain and poor sleep without the patch, while family and staff confirmed ongoing pain and missed doses.
Two residents experienced significant medication errors when ordered meds were not available or not administered as prescribed. One resident on hospice went more than 24 hours after admission without ordered Morphine for pain and air hunger, while another resident missed multiple doses of a Lidocaine patch and Mirabegron because the meds were out of stock or not obtained from the pharmacy, with the DON confirming the missed doses and unrelieved pain were significant.
A resident with a TLSO brace and limited mobility developed a worsening buttock pressure ulcer that was not fully assessed, not promptly communicated for treatment changes, and not consistently covered by timely antibiotic therapy while infection and pain were documented. The wound later deteriorated with tunneling, necrotic tissue, and a new coccyx pressure ulcer that progressed to Stage IV with osteomyelitis after hospital transfer. A second resident had pressure-related skin breakdown with delayed wound assessments and treatment orders, no added individualized care plan interventions, and a CNA provided care without gown and gloves despite EBP being in place.
An unlocked medication cart containing numerous loose, unlabeled medications was observed in the facility library, an area accessible to residents, visitors, and staff. The DON confirmed the cart had a broken lock and had been in the library for at least two weeks, while residents and family members stated the library was open to everyone and that the cart could be accessed by anyone nearby.
Menus and Recipes Not Followed: A resident reported that orange juice and milk were not consistently served and that potatoes were sometimes too hard to eat. During meal observations, residents were served items that did not match the posted menu, including a cold tuna sandwich instead of a tuna melt and missing listed sides such as coleslaw and mandarin oranges. The DON and RD stated the kitchen was selecting only one of the listed menu items in some meal categories and that the tuna melt recipe required toasted bread and heating until the cheese melted, which was not done.
Meals and snacks were not consistently served at posted times, with residents and CNAs reporting repeated delays for breakfast and lunch. A resident council president said late trays shortened dining time in the main dining room, another resident said he sometimes waited up to an hour, and a resident on the 3rd floor was still waiting for breakfast when the surveyor observed the tray had not arrived by the posted time. The DON, Dietary Mgr, and RD acknowledged meals should follow the schedule, and resident council minutes and a grievance form documented ongoing complaints about food not being on time.
A resident reported a roach in a juice cup, and staff confirmed the cup should not have contained an insect. Surveyor observation of the low-temp dish machine found the chlorine test strip stayed white, and the dietary supervisor stated there was no chemical sanitizer feeding into the machine because the sanitizer barrel was too low. Staff and residents also reported repeated problems with cloudy, dirty plastic cups, and a CNA said she had seen a live roach in a cup the prior week.
No full-time RN DON was designated in the facility. Staff, including an RN, an LPN, the ADON, and the Administrator, stated there was no current DON, and the Regional Nurses were not at the facility full time because they covered multiple facilities. The facility had 55 residents, all requiring skilled nursing services.
Meals were not consistently served at scheduled times, with residents reporting late breakfast and supper service and some trays arriving well after posted meal times. Observations showed supper trays being delivered late, including to residents who said they were hungry but felt it was too late to eat, and breakfast trays not fully delivered until after 9:00 AM. Staff attributed the delays to kitchen staffing shortages, unfinished cleanup, and meal card issues, and the ADM acknowledged the problem was ongoing.
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.