Staff failed to follow EBP and infection control practices during resident care and linen handling. Two CNAs provided hands-on care to a resident with open wounds without gowns, administrative nurses measured and photographed wounds with gowns not secured and without hand hygiene when changing gloves, and staff carried uncovered linens against uniforms and entered multiple rooms without hand hygiene between rooms.
Failure to designate a qualified IP for the IPCP. An interim nurse said she could not locate her IP certificate, had not really completed much of the IP duties, and was only enrolled in IP courses. Another admin staff member thought the interim nurse had a current IP certificate and expected the facility to have a designated certified IP. The facility did not provide an IP policy.
The facility failed to maintain an in-service training program for CNA staff with the required topics and at least 12 hours per year. Review of five staff files showed missing annual training hours, and several staff lacked required dementia education; one CMA also lacked training on abuse, neglect, and exploitation. Administrative Staff A stated that CNAs were expected to have the required training, and no staff training policy was provided.
Incomplete CAA Documentation for Comprehensive MDS Assessments: The facility failed to complete required CAA analysis of findings for multiple residents after comprehensive MDS assessments. Missing CAA documentation involved triggered areas such as functional abilities, cognition, communication, falls, nutrition, dehydration, pressure injury, psychotropic drug use, urinary incontinence, pain, and psychosocial well-being. Survey staff confirmed the comprehensive MDSs were completed offsite by an RN, but the CAA records lacked source documentation and individualized analysis of the collected data.
Medication Error Rate Exceeded 5 Percent: The facility had a 7.41% medication error rate after two errors were identified. A resident ordered acetaminophen and Refresh Tears received acetaminophen and artificial tears instead of the ordered eye drops, and the CMA reported giving the meds with the morning pass and not notifying an LN that they were late. The pharmacist confirmed the eye drops and artificial tears were not the same medication, and the regional RN stated meds should be given within one hour before or after the scheduled time.
Missing COVID-19 Vaccine Offer and Documentation: The facility failed to document that several residents were offered the COVID-19 vaccine or had informed declinations on file. EMR review showed no vaccine-offer documentation for multiple residents over several years, and staff could not confirm current consents or declinations. For staff, the COVID education materials reviewed during orientation covered COVID symptoms and masking, but did not include vaccine education or how to obtain the vaccine, despite verbal education being reported.
A resident left the facility against medical advice, but the EMR lacked documentation that the LTC Ombudsman was notified in writing of the discharge. In a separate case, another resident was discharged to the community, but the record lacked a discharge summary with a recap of the stay and medication reconciliation; staff stated nursing and social services were responsible for discharge documentation and planning.
Failure to provide ADL care and hygiene assistance: One resident with Parkinson’s disease, DM2, dysphagia, and polyneuropathy was scheduled for showers twice weekly but had no documented bath or shower for nearly two weeks and was observed with dirty clothing, skin flakes, messy hair, and facial stubble. Another resident with parkinsonism and Alzheimer’s disease, who required maximal assistance with personal hygiene, was repeatedly observed with dirty fingernails. Staff stated nails should be cleaned when dirty and checked daily, but the resident’s nails remained unclean.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Influenza vaccine consent and declination documentation was incomplete for two residents. One resident received the flu vaccine without documented education, and another resident declined the vaccine without documented education or a signed declination form. Administrative staff reported there were no current signed consents or declinations, and the facility policy required use of the Patient/Resident Declination/Authorization Form.
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.