A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans and to carry out existing interventions for three residents. One resident with paraplegia and a urostomy managed her own drainage by attaching catheter tubing to her pouch and hanging the tubing over a trash can without performing hand hygiene, and her care plan lacked interventions addressing her self-care and hand hygiene despite her cognitive intactness. Another resident with hemiplegia had a physician order and care plan for a left-hand splint to be worn a set number of hours daily, yet repeated observations showed the splint unused by the TV and no documentation of implementation in the record. A third resident with hemiplegia had orders and a care plan for a right resting hand splint and a left palm guard, but observations over several days showed the right splint not in place and sitting on the bedside table, while staff interviews revealed inconsistent awareness and follow-through on splint orders and care plan directives.
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, and staff did not consistently follow existing care plan interventions. Several residents with PEG tubes, a dialysis catheter, and a colostomy either lacked appropriate EBP care plan focuses at admission or did not have EBP practices implemented as written, including missing door signage and failure to follow tube-feeding protocols. In addition, two residents with PTSD and other mental health diagnoses had active PTSD documented in assessments and psychiatric notes, but their care plans did not address PTSD-related triggers, symptoms, or trauma-informed interventions, despite staff acknowledging these omissions and the importance of accurate, complete care planning.
A resident admitted with PTSD and other diagnoses had a trauma-informed care assessment showing distressing trauma symptoms, but the comprehensive care plan did not address PTSD or include trauma-informed interventions. Staff interviews confirmed the diagnosis was known, yet the care plan lacked the information needed for nursing, CNA, MDS, SSD, DON, and ED staff to identify needs, triggers, and resident-centered interventions.
Failure to develop a care plan for a resident’s tracheostomy care. The resident had a tracheostomy, COPD, chronic respiratory failure with hypoxia, and received oxygen therapy, suctioning, and tracheostomy care. The care plan addressed communication difficulty related to the tracheostomy, but it did not include a tracheostomy or respiratory services focus area. Staff and the DON confirmed there was no tracheostomy-specific care plan, despite an order for tracheostomy care every shift.
A resident with pneumonia, atrial fibrillation, coronary artery disease, and hypertension was admitted with an IV antibiotic infusion and ordered weekly weights. The care plan required staff to monitor for cardiac dysfunction, including edema, and to notify the physician of significant weight changes, consistent with facility policy. Over approximately two weeks, the resident gained more than 17 pounds and developed progressive edema observed by family, but there was no documentation that nurses notified the physician or consistently assessed for edema. Staff interviews confirmed lack of physician notification and incomplete assessment practices, and the APRN reported not being informed of the weight gain until the day of hospital transfer, where the resident was admitted with fluid overload and MI and later expired. Surveyors cited the facility for failing to develop and implement a comprehensive, resident-centered care plan, including resident-specific interventions for continuous IV fluids and timely response to significant weight changes.
A resident with multiple chronic conditions had a documented Full Code status and an advance directive care plan requiring CPR to honor the resident’s wishes. When the resident was found unresponsive, not breathing, and cold to the touch, a KMA and an RN assessed the resident but did not initiate CPR, and no documentation showed that life-saving measures were attempted. Staff interviews revealed that the RN was unaware of the resident’s code status, the KMA did not verify it or initiate emergency procedures, and both relied on the KMA’s outside role as a deputy coroner rather than following the care plan, resulting in the resident’s death without implementation of the ordered Full Code interventions.
A resident on Hospice with CKD and HF did not have the CCP updated to include Hospice-oriented goals or interventions for comfort-focused care. The MDS Coordinator stated Hospice status should be reflected in the care plan, and the DON, Administrator, and Medical Director all stated care plans were expected to guide staff in meeting resident needs.
A resident with DM2, neuropathy, and a prior stroke had a care plan requiring two staff for transfers and personal care, but an SRNA provided care and completed transfers without another staff member present. During observation, the resident became weak and swayed while being assisted, and staff interviews confirmed the resident required two-person assistance and that care plan interventions were expected to be followed.
Incomplete PTSD Care Planning: The facility failed to develop and implement person-centered CCPs with measurable interventions for two residents with PTSD histories and known triggers. One resident with a history of stroke, depression, anxiety, insomnia, and PTSD had no PTSD interventions in the admission care plan and later required hospital psychiatric care after an acute behavioral episode; staff were unaware of specific triggers. Another resident with PTSD, anxiety, and diabetes had no PTSD care plan for over a year, despite reports of sexual assault trauma, loud-voice sensitivity, and a preference for female caregivers. Interviews showed staff knew the diagnoses but lacked complete trigger information in the care plans.
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 June 24, 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.