Failure to Follow Contact Precautions for C-diff: A resident with C-diff was on Contact Precautions, with PPE available and signage posted at the room entrance. Surveyors observed an LSW in the resident’s room without a gown or gloves, and the RN Mgr stated PPE was only needed if touching items before later correcting the staff member. The facility policy required PPE to be worn before or upon entry for residents on Transmission Based Precautions, including C-diff.
Infection control failures were observed involving EBP, PPE, and urinal handling. A resident with an indwelling catheter and another resident with a catheter had no EBP signage posted, an LPN performed trach care for a resident with chronic respiratory failure and a tracheostomy without face protection, and two unlabeled urinals were found hanging in a shower room.
The facility failed to complete an annual review of its ICP and did not document any update or revision of the program. The IP stated she did not know whether the ICP had been reviewed, and the Administrator confirmed that no annual review had been completed.
The facility failed to implement and support an effective infection prevention and control program when a resident on contact precautions for ESBL in the urine was cared for by an LPN who entered and exited the room to administer medications without donning required PPE, despite posted instructions and available supplies. Staff interviews revealed misunderstanding of when gowns and gloves were required and lack of familiarity with EBP, with a CNA stating the facility does not use EBP and that PPE is not needed if direct care is not provided. Review of the infection control manual showed no written EBP policies, and the DON acknowledged she had assumed EBP were in place but was unaware they were not included in the manual.
The facility failed to ensure its infection prevention and control program included clearly visible entrance signage alerting visitors to an active coronavirus outbreak. The DON informed surveyors of multiple active coronavirus cases on two units and instructed them to wear masks, but when the survey team entered earlier there was no clearly visible outbreak notice at the entrance. A sign requiring all visitors to wear masks was later shown to surveyors on the top of the reception desk, but it was not readily visible upon entry.
The facility failed to maintain its infection prevention and control program when a surveyor observed a soiled bed pan stored on the floor under a resident's bed. An LPN stated that bed pans are reused, washed, bagged, and should not be stored under a resident's bed, and the used bed pan was later observed and confirmed under the bed.
Infection control failed when a resident's fabric chair was observed with dark brown and light brown substances on the seat, and brown spots were also seen on the bathroom floor. A CNA stated the resident often is incontinent with diarrhea, and the observations were confirmed by the Maintenance Director and Regional Director of Operations.
The facility failed to follow its infection control policies by not ensuring staff wore gown and gloves in rooms under EBP and Contact Precautions and by not discarding a pill that fell onto the medication cart. Staff were observed providing direct care and medication administration to residents with foley-related EBP and shingles-related Contact Precautions without the required PPE, and a CNA-M attempted to reuse a pill that had fallen onto the cart before it was ultimately placed for disposal.
Infection Control Lapse During Wound Care and Soiled Linen Handling: An RN performed wound care for a resident with left leg wounds on Contact precautions for shingles, using a towel under the resident’s leg while the open wounds were in direct contact with it. After the dressing change, the RN placed the unbagged soiled towel on a shared sink counter, carried it with bare hands to the soiled utility room, and later cleaned bandage scissors in the sink without first cleaning the sink counter.
The facility failed to post entrance signage alerting visitors and staff to an active Flu outbreak, even though the DON confirmed the outbreak was ongoing. Staff were also observed not following PPE requirements for residents on contact, droplet, and enhanced barrier precautions: a RN entered a contact precaution room without PPE, a CNA entered a droplet precaution room without PPE before delivering a meal tray, an LPN disconnected a J-tube feed without a mask, and another CNA doffed PPE in the hallway and handled a clean mask and meal cart without sanitizing hands. A resident with Influenza A and a resident with VRE were among those affected by the observed PPE failures.
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.