Incomplete neurological assessment documentation after resident falls. A resident had one fall with a hematoma and another fall with a head injury and forehead laceration requiring ER transfer and sutures. Although staff stated neuro checks were done and the resident remained stable, the record lacked required 72-hour Neurological Flow Sheet documentation, including LOC, pupil response, hand grasps, and vital signs, and one flow sheet was incomplete while the other was not found in the chart.
Medications were documented as administered before they were actually given for multiple residents. An LPN was observed preparing and giving meds while the EMR already showed them as signed off earlier, and she stated her usual practice was to chart meds when she pulled them from the cart. The DON stated the LPN should not have marked meds as given until after administration and said she knew meds were being given late but was not aware of the false documentation.
Inaccurate documentation of a resident fall: A resident on the memory care unit had a fall that was documented as witnessed while walking to the bathroom with a CNA, but the CNA later stated he was caring for the roommate in the bathroom and did not witness the fall. The DON confirmed the discrepancy, and the Administrator said the initial IDPH report was based on the inaccurate progress note. The facility policy required accurate nurses’ notes.
Incomplete and Inaccurate Resident Medical Records: The facility failed to keep accurate clinical records for multiple residents. A resident’s bruise was documented inconsistently, with an RN denying she witnessed the injury and no complete skin assessment or monitoring documented. Another resident’s elopement event was not entered into the medical record, and Wanderguard checks were missed or recorded on the wrong ankle. A third resident’s Wanderguard was documented for the left ankle but was observed on the right ankle.
Inaccurate resident record documentation was identified for a resident whose chart stated that the Medical Director and another physician assessed the resident and imaging, including findings about a possible rib fracture and no pain with PROM. Interviews showed the Medical Director only reviewed radiographs and did not physically assess the resident, and the other physician stated he was asked to review the x-rays, was not the resident’s provider, and did not physically assess her.
Inaccurate behavioral documentation was found for three residents with behavioral health needs. One resident’s records did not reflect a reported verbal incident involving another resident, while two other residents had nurse notes and witness statements describing yelling, verbal aggression, and a verbal altercation that were not captured on the behavioral tracking sheets. The DON and Administrator stated behavior tracking must be completed every shift and that staff were being educated to ensure accurate documentation.
Failure to document frequent seizures and PRN anticonvulsant use: A resident with epilepsy reported having seizures all the time, and staff said seizures occurred almost every day or every other day. An LPN said Valtoco was used during seizures, but the MARs did not document administration, the progress notes had no seizure documentation, and the controlled drug record showed doses were given without corresponding charting.
A resident with multiple chronic diagnoses developed an itchy, scattered rash that was documented in nursing notes and wound records, but the chart did not consistently reflect the dermatology diagnosis. The dermatologist assessed scabies and ordered permethrin and ivermectin, yet a progress note was edited from scabies to skin rash. Staff interviews showed the RN had originally documented scabies but was told by the DON and ADON to change it, and the DON acknowledged documentation problems and said staff were looking for symptoms for the charting.
A resident admitted after hospitalization for RLE cellulitis and an abscess following a fall had conflicting admission dates in the census and MDS, inaccurate fall history and BIMS documentation, and missing admission documentation. Staff confirmed the hospital paperwork was not obtained on the actual admission date, the admission assessment was not completed then, and there was no documentation that the physician was notified or that hospital discharge orders were entered into the EMR and sent to the pharmacy.
Inaccurate documentation of protective sleeve refusal. A resident with an order to wear protective arm sleeves while up in a wheelchair was observed multiple times without them, and the resident said staff did not offer the sleeves. However, the TAR documented the sleeves as applied every day, and the care plan did not include the intervention. The DON stated the sleeves are meant to prevent skin tears and abrasions and that staff should not sign them off if the resident is refusing.
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.