Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
Incomplete neurological and wound documentation was found for two residents with unwitnessed falls and one resident with a right heel pressure injury. Neuro checks after falls were not fully documented at required intervals, and the wound record lacked staging, measurements, and description while the chart contained conflicting pressure injury stages from the RN, NP, and wound clinic records.
A resident with atrial fibrillation was receiving Eliquis (apixaban) twice daily as ordered, and the MAR showed doses were given as scheduled. Following two separate falls, staff completed SBAR Communication Forms and progress notes to notify the provider of the change in condition. However, on both occasions, the Background section under Medication Alerts on the SBAR forms did not indicate that the resident was on an anticoagulant, despite the form’s directive to complete relevant sections before contacting the MD/NP/PA. During interviews, facility leadership confirmed that the SBAR documentation for these falls failed to reflect the resident’s anticoagulant therapy, resulting in incomplete and inaccurate clinical records.
Incomplete MAR/TAR Documentation for Ordered Medications and Treatments: Multiple residents had missing MAR/TAR entries for ordered meds, treatments, assessments, and monitoring, including insulin and BG checks, wound and skin care, enteral feeding tasks, HOB elevation checks, psych med side-effect monitoring, and other ordered nursing interventions. The Market Clinical Advisor confirmed the missing documentation during interview.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
Incomplete and Inaccurate Clinical Records: Multiple residents had TAR entries showing identical vital signs and/or weights repeated over several consecutive days despite monthly monitoring orders. For one resident, the provider noted repeated BP readings that were exactly the same, and the DON stated the system was pulling prior results when staff did not enter new data; the surveyor confirmed the records were inaccurate.
A resident’s clinical record was found to be incomplete and inaccurate when staff documented pacemaker monitor checks on the TAR using a code indicating “drug not available,” which was inappropriate for this treatment and acknowledged as incorrect by the RN. In addition, a surveillance UA dip ordered to verify resolution of a UTI was signed off as completed, but no UA result was documented in the record or attached to the physician order, and the RN reported he performed the test but did not chart or file the machine-generated results.
Inaccurate clinical record documentation was found for three residents. One resident’s chart incorrectly stated that a Foley catheter was not in place despite admission with an indwelling catheter, another resident’s wound records and care plan identified the wrong heel for a pressure injury, and a third resident’s activity record documented participation after the resident had already died. The DON, RN2, and Staff Development Coordinator confirmed the inaccuracies.
Incomplete and inaccurate clinical records were found for two residents. One resident's chart contained conflicting code status entries, including CPR active, DNR, and do not intubate documentation. Another resident's Keppra order for epilepsy was entered incorrectly as an unsupervised self-administration medication, and the resident missed 40 doses because the resident was not actually self-administering medications.
Incomplete and inaccurate clinical record for a resident with a left hip fracture and surgical repair. The chart still contained active orders for elevating the affected extremity, using an incentive spirometer, and reporting persistent drainage even though staff stated the resident no longer had a surgical wound, the left leg was no longer being elevated, and the incentive spirometer was no longer being used.
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.