A resident with a chronic scalp lesion had ongoing drainage and foul odor, but the wound was not adequately evaluated or managed despite repeated skin assessments documenting the condition. No wound care orders were in place until maggots were found and removed, and staff did not complete a comprehensive reassessment afterward. The resident was not seen by a provider until several days later, when a surgeon documented fly-laid maggots, drainage, odor, and growth, and a biopsy later showed basal cell carcinoma.
EBP was not identified or initiated for residents with wounds, a skin lesion, or an indwelling Foley catheter, as signage was missing and PPE was not readily accessible at the point of care. In addition, a staff member distributing clean linen entered multiple residents’ rooms and handled clean clothing without performing hand hygiene before entering, after exiting, or before touching clean linen.
Failure to Notify Physician of Wound Change: The facility did not notify the MD of a significant change in condition for a resident with a chronic scalp wound when new drainage developed. The wound was observed with black discoloration, drainage, and a foul odor, and skin assessments documented drainage, but nursing notes showed no documentation that the MD was informed. Staff stated the MD should be notified of wound changes such as drainage, size, shape, or color, though notification was handled case by case.
The facility failed to fully assess and document a resident’s chronic scalp wound. Weekly skin checks noted the lesion at times, but documentation lacked wound size, shape, color, and full drainage details, and no comprehensive skin assessment was documented after maggots were removed. Staff stated wound changes should be reported and documented, but the record did not show complete follow-up assessment of the wound.
Failure to provide physician reassessment after a significant change in condition: a resident with a large, foul-smelling scalp lesion was found to have maggots in the wound. Staff notified the MD, who gave wound care instructions by phone, but did not come to assess the resident or document a reassessment before the resident’s outpatient surgery visit.
Incomplete Documentation of Chronic Scalp Wound: A resident with a chronic scalp lesion/wound had inconsistent and incomplete skin/wound documentation in the EMR. Weekly skin assessments sometimes omitted the lesion entirely, and when it was documented, key details such as size, shape, color, and drainage were missing. The record also lacked documentation of a comprehensive assessment after maggots were found and removed from the wound, and staff acknowledged the chart did not provide a complete picture of the wound status or care provided.
Controlled Substance Documentation Discrepancies: The facility failed to accurately account for and document controlled substance doses for three residents. MARs and narcotic sign-out records did not match for multiple doses, with some doses documented on one record but not the other. Staff stated that MAR documentation and narcotic sign-out sheets should match and that every narcotic dose needed to be documented on both records.
Resident dignity and rights concern during activity: A resident had an incontinent episode during a group activity and had to leave to be cleaned up after an LPN loudly announced in front of others that there was a big mess needing attention. Staff later reviewed the event and described it as involving resident dignity and rights, with the LPN stating she was frustrated while caring for the resident due to the resident’s intellectual disability.
A caregiver violated a resident’s privacy during incontinence care by using a personal cell phone to contact an outside CNA who was not employed by the facility while the resident was present. Staff observed the caregiver on a video call, and a written statement noted the camera was turned toward the resident’s buttocks area and the mess on the floor.
Failure to Protect Resident from Staff Abuse: A staff member yelled at a resident during an activity session after the resident had a BM and continued making comments about the mess in front of the resident. A witness reported the staff member was going off about how big and gross the mess was, and the resident was later found in her wheelchair without pants or a brief, with BM on the bathroom walls. The resident was also documented as almost falling from her w/c and needing a Hoyer lift and shower chair for cleanup due to diarrhea.
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.