Failure to Monitor and Respond to Prolonged Absence of Bowel Movements: A resident with constipation, dementia, severe cognitive impairment, and bowel/bladder incontinence had no documented BM for 13 consecutive days. The record lacked documentation of bowel monitoring, progress note follow-up, or administration of ordered PRN constipation meds, despite staff stating they used a 3-day no-BM list and would give MOM or a suppository. The facility policy also lacked monitoring and follow-up after 72 hours without a BM.
Failure to Apply Ordered Ace Wraps for Dependent Edema: A resident with edema, CHF, and daily diuretic use was ordered Ace wraps for his legs, but staff did not consistently apply them and sometimes charted them as applied when they were not. Surveyors observed the resident without the wraps on multiple occasions, and the resident said the wraps rarely happened unless he reminded staff. An LPN acknowledged the inaccurate charting, and an Administrative Nurse stated refusals should be documented instead of recording application when the wraps were not on.
A resident with PVD, osteomyelitis, and recent toe amputations had ordered wound vac therapy for a right foot surgical wound. An LPN placed Aquacel AG under the wound vac despite the TAR, and the wound care clinic later found the dressing had clogged the vac, the wound had worsened with more necrosis and pain, and the resident was sent to the ED for further evaluation. The nurse said there were conflicting orders and she did not verify the correct one.
Failure to Follow Transfer Care Plan and Respond to Change in Condition: A resident with hypotension, dementia, DM2, CKD, and HTN was supposed to be transferred with a full-body mechanical lift, but staff used a sit-to-stand lift instead and the resident passed out. The nurse documented initial VS and brief assessment findings, but the chart lacked follow-up documentation, and staff stated they had stopped calling the MD when the episodes occurred even though the event was a change in condition.
A resident with Alzheimer's disease, dementia, anemia, and PVD had a pressure-related wound and orders for a foot cradle and Prevalon boots while in bed. Staff observations showed the cradle and boots were not in place, and later the blankets were resting directly on both feet despite the ordered interventions. Nurses and a CNA stated the devices should have been used as ordered.
A resident with DM, constipation, and vascular dementia went more than 72 hours without a BM on two separate occasions, each lasting six consecutive days, before any response was documented. The resident had orders for Colace and PRN bisacodyl, but EMR notes show PRN Milk of Magnesia was offered only after the prolonged no-BM periods, with the resident refusing medication and prune juice on one occasion and later receiving Milk of Magnesia on another. Staff interviews stated the charge nurse was responsible for reviewing the 72-hour no-BM report, offering PRN meds, completing an abdominal assessment, and notifying the provider if no BM occurred for several days.
A resident with stroke, dementia, and dysphagia was care planned as needing monitoring for chewing and swallowing problems and was admitted on a CCHO/LCS diet with regular texture. After episodes of coughing and difficulty swallowing meat, SLP evaluated the resident, and a FEES study recommended a minced and moist mechanical soft diet, medications in puree, upright positioning during and after meals, and double-swallow strategies. SLP documentation later described the resident as on a mechanical soft diet with thin liquids and pills crushed in puree, requiring total supervision at meals, but the EMR contained only an ongoing order for a regular-texture CCHO/LCS diet with no documented diet changes. The swallow study was scanned into the EMR under a miscellaneous tab without an alert, there was no documented provider notification or response, and the nurse who reported calling the provider and being told to continue the regular diet did not enter a progress note. Staff interviews showed uncertainty about how SLP recommendations and test results were communicated and processed, and no relevant policy was provided.
A resident with hypotension and intact cognition was started on an antihypotensive medication, with care plan directions to monitor blood pressure and pulse and to assess for side effects and effectiveness. After the resident reported low blood pressure and symptoms of dizziness and lightheadedness, a provider ordered orthostatic blood pressures twice daily for three days, including lying, sitting, and standing measurements, with results to be sent via EMR message. The EMAR showed that on multiple days only single blood pressure readings were documented, required orthostatic positions were missing, and some ordered evening orthostatic sets were not recorded at all, with one complete set documented only in a nurse’s note due to EMR entry issues. Staff interviews confirmed that CNAs usually obtained vitals, nurses later entered them, orthostatic technique varied, and required EMR messages with results could not be located, and no policy on orthostatic blood pressures was provided.
A hospice resident with a history of stroke, depression, anxiety, psychosis, insomnia, and impaired mobility had an established psychotropic regimen including clonazepam, lorazepam (Ativan), and Seroquel to manage terminal agitation and behavioral symptoms. After admission to hospice, an administrative nurse insisted the resident could not receive both clonazepam and Ativan, pressured staff to contact the PCP, and clonazepam was abruptly discontinued without hospice being notified, despite the PCP’s original plan to taper it gradually. Following this change, documentation showed the resident became increasingly agitated, paranoid, confused, and tearful, refused care and medications, attempted unsafe activities such as trying to leave his room and facility, and sustained an unwitnessed fall with a skin tear and low back discomfort, requiring more frequent narcotic pain medication. The resident’s DPOA and hospice staff reported that the resident’s behaviors and anxiety worsened after clonazepam was stopped and that they felt pressured by facility leadership to alter the medication regimen that had previously kept the resident more comfortable.
A resident with dementia, chronic constipation, and orders for daily and PRN laxatives went nine days without a documented BM. During this period, ordered Enulose doses were missed on several days because the resident was sleeping, PRN Milk of Magnesia was never given, and there was no documentation of bowel or abdominal assessments. Staff relied on limited electronic bowel documentation and printed reports, and although a standing bowel protocol and assessment requirements were in place for residents approaching three days without a BM, there was no evidence these were initiated or documented for this resident.
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