Air Mattress Set Incorrectly for Resident With Sacral Pressure Ulcer: A resident with a sacral pressure ulcer, severe cognitive impairment, malnutrition, and other chronic conditions was observed multiple times resting on an air mattress that was set above 350 lbs., even though the resident weighed 120 lbs. The resident’s orders included daily wound care and an air mattress with bolsters, and staff documented checking the mattress each shift. The DON, UM, and an RN stated the mattress should be set to the resident’s weight and that the setting in use was too firm for the resident.
The facility failed to carry out ordered wound care and pressure-relief interventions for multiple residents. One resident’s ankle wound present on admission was not adequately assessed, monitored, or treated and later was documented as a Stage 4 pressure injury. Another resident’s Wound NP recommendations were not transcribed or implemented, and the resident’s air mattress was repeatedly found set far above the ordered weight-based setting. A third resident’s sacral wound care was not followed as ordered, the wound was not measured weekly, and the air mattress was also set too firm. A fourth resident’s heel wound dressing was not provided according to the physician’s order.
Failure to Implement Wound Consultant Treatment for Pressure Ulcer: A resident with severe cognitive impairment, DM2, and a stage 4 pressure ulcer had a wound consult that recommended a new dressing regimen for a left ankle wound. The chart showed the prior wound order continued to be carried out daily, and the revised wound treatment was not implemented into the resident’s plan of care.
Air Mattress Set Incorrectly for Resident With Pressure Injuries: A resident with a stage 2 pressure ulcer and an unstageable deep tissue injury had an air mattress ordered for pressure relief and to be set per weight, but staff observed the compressor set to 280 lbs even though the resident's recorded weight was 193 lbs. An LPN reviewed the record and stated the mattress was set too high and should be set close to the resident's weight.
A resident with advanced dementia and hospice services had multiple pressure ulcers, including a stage 3 heel ulcer and a new buttock ulcer. Staff observed the air mattress set above the ordered weight even though the TAR showed it was signed off as correct, and the heel wound treatment orders were not entered clearly in the EMR, leaving no assigned time or reliable documentation to show which ordered treatment was actually provided. Nurses and the DON stated they could not tell from the record which heel treatment had been completed.
Failure to Implement Updated Wound Treatment Orders: A resident with multiple pressure ulcers, severe cognitive impairment, diabetes, and hemiplegia/hemiparesis did not receive the Wound MD’s updated sacral wound treatment recommendations. Nursing continued the prior Santyl-based order on the TAR even after the Wound MD directed calcium alginate and a superabsorbent dressing, and staff interviews confirmed the updated orders were expected to be entered promptly but were not in place.
A resident with diabetes, impaired mobility, pain, and high skin-breakdown risk did not receive consistent diabetic foot care, weekly skin checks, or timely response to a new red, non-blanchable heel area identified by therapy. Staff could not consistently visualize the foot because of an ace wrap that was not ordered, therapy reported the need for offloading and prevalon boots, and the heel later progressed to an unstageable pressure injury. After the wound was identified, the resident was still observed on a regular mattress despite an order for an air mattress, and staff gave inconsistent reports about whether it was being used.
Failure to float heels for a high-risk resident. A resident with DM, a right foot ulcer with muscle necrosis, and depression had an order to elevate legs and float heels while in bed. The resident was rated very high risk for pressure ulcers, but surveyors repeatedly observed both heels directly on the mattress, and the record did not show refusal of the ordered intervention. Staff interviews confirmed the order should have been followed and that the CNA did not recall seeing the heel-floating requirement.
Failure to elevate heels for a resident at risk for pressure ulcers. A resident with severe cognitive impairment, total ADL dependence, and a care plan/order for heel elevation was observed multiple times lying in bed with both heels directly on the mattress. Staff stated that CNAs and nurses were responsible for following the care plan and documenting any refusal or inability to tolerate the intervention.
Failure to Follow Pressure Ulcer Orders: A resident with dementia and a stage 3 unhealed heel pressure ulcer had orders to offload the wound every shift, float the heels in bed, and apply a specific daily dressing. Surveyors observed the resident's heels flat on the mattress in bed on multiple occasions and the feet resting on wheelchair supports, and during wound care an incorrect bordered gauze dressing was used instead of the ordered bordered foam dressing. The UM, Infection Prevention Nurse, and DON confirmed the ordered heel offloading and dressing were not followed.
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.