Failure to Verify Advance Directives Before CPR: A resident with severe cognitive impairment, Parkinson’s Disease, and a MOLST indicating DNR and comfort measures only became unresponsive. An LPN who was unfamiliar with the resident’s plan of care activated the emergency response system and started CPR without first checking the MOLST or confirming the resident’s code status, even though the HCP later stated they did not want CPR or other life-sustaining treatment.
Failure to Notify MD of Med Refusals: A resident with dementia, HTN, and a prior MI repeatedly refused ordered meds, including a beta blocker for HTN and an antibiotic for pneumonia. Facility policy required reapproach, documentation, and MD notification for refusals, but interviews showed inconsistent staff understanding and no recall by the MD of being notified about the refusals.
A resident with constipation risk did not receive the ordered bowel protocol after several days without a documented BM, and the ordered laxative was not administered. Another resident with a suprapubic catheter had a dressing change order that was not followed for days, the family’s concern was not promptly escalated, and a wound culture was mislabeled, leading to delayed care and empiric antibiotics.
Failure to Complete and Accurately Document Required Resident Monitoring: Two residents ordered for 30-minute visual checks did not receive proper documentation. One resident’s CNA pre-filled monitoring entries before the observation times occurred, while another resident had no documented checks for several hours and the reason for monitoring was left blank. Staff stated they did not know the meaning of the form designation or why the resident was on checks, and the DON said monitoring should be documented in real time.
A resident with no documented DM diagnosis was ordered Mounjaro and later developed symptomatic hypoglycemia requiring glucagon and ED transfer. Another resident with bilateral forearm graft sites had loose, non-intact dressings left in place for hours after staff were notified, with exposed reddened areas and bleeding noted. Staff interviews confirmed the dressings should have been changed much sooner.
Two residents did not receive ordered care as documented. One resident’s 9 AM meds, including BP, CHF, and asthma treatments, were omitted until mid-afternoon, and staff acknowledged the LPN did not give the meds on time or seek help. Another resident with urinary symptoms had a UA/C&S order that was not collected for several days, and there was no documented physician notification when staff could not obtain the specimen. The record showed the resident was incontinent and symptomatic, with delayed specimen collection and incomplete communication.
Delayed post-fall monitoring and imaging after unwitnessed fall. A resident with encephalopathy, AFib, CKD, and severe cognitive impairment fell from bed while receiving Eliquis and sustained a large skin tear to the right forearm. The incident report called for neuro checks and x-rays of the right shoulder and forearm, but there was no documented evidence that the one-hour neuro checks were ordered or completed in a timely manner, and no documented evidence that the imaging was completed before the resident was transferred to the ER.
A resident with dementia, impaired mobility, and muscle weakness had an unwitnessed fall that was not immediately reported by a CNA or assessed right away by a qualified staff member. The fall was later learned about when the resident told the spouse, and the resident had bruising to the left chest/abdomen area. The MD ordered a chest/rib x-ray to rule out fracture, but there was no documentation that the imaging was completed before the order was discontinued.
A resident with bilateral leg cellulitis, lymphedema, and marked edema did not receive ordered wound care as scheduled. Observations showed kerlix dressings left in place for days, heavy drainage on one dressing, and Coban compression wraps not applied even though they were ordered from toes to knees. Staff interviews confirmed the treatments were not completed as ordered and that the provider was not notified when they were missed.
A resident with chronic anemia, AFib, and anxiety had a hematology consult ordered and repeated CBC/Mg labs entered, but the consult was not completed and the bloodwork was delayed for 14 days. Staff described breakdowns in the lab-order process between the NP, ward clerk, and phlebotomy, while the resident and family reported repeated concerns about fatigue, weakness, and the need for timely bloodwork. The resident later had critical Hgb values, was sent to the hospital for emergency transfusion, and the hospital documented acute on chronic anemia.
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.