Two residents on contact isolation or Enhanced Barrier Precautions (EBP) did not receive care in accordance with posted PPE requirements and facility policy. One resident with MRSA and multiple antimicrobial-resistant infections had contact isolation and EBP signage and an isolation cart with PPE at the door, yet an LPN entered and remained in the room without donning a gown or gloves, despite acknowledging the resident’s contact isolation status. Another resident on EBP related to a condom catheter had door signage directing staff to wear gowns and gloves for direct care, but a CNA twice provided dressing assistance and peri-care while wearing only gloves and no gown, later stating he had forgotten to don the gown. The DON confirmed the first resident should have been on contact isolation with gowns and gloves used upon room entry, and the Infection Preventionist confirmed that EBP was not appropriate for the first resident and that staff are expected to use gowns and gloves for residents on EBP during direct care, consistent with the facility’s EBP policy.
A resident’s nasal cannula tubing and CPAP mask were observed on the floor on two occasions, rather than stored in a clean, covered manner as required by facility policy. A CNA reported finding the equipment on the floor at the start of her shift and stated she had informed the charge nurse and requested appropriate storage supplies. An RN and an LPN both acknowledged the equipment should not be on the floor and should be kept in labeled bags, while the DON stated the resident was known to remove his oxygen and was unaware that the tubing on the floor was attached to an oxygen concentrator used at bedtime. The facility’s respiratory care policy requires safe storage, covering of oxygen cannulas and masks when not in use, and clean, labeled storage for CPAP equipment, which was not followed in this case.
Infection control practices were not followed for two residents on contact precautions and during medication administration for another resident. A CNA entered a room under contact precautions without gown or gloves, and a staff member entered another contact precautions room without hand hygiene or PPE before handling meal trays. In addition, an RN administered oral meds, eye drops, and an injection without changing gloves or sanitizing hands between tasks, despite facility policy requiring hand hygiene and glove changes.
An LPN failed to follow the facility’s infection control procedure when disinfecting a resident-dedicated glucometer after blood glucose monitoring. The LPN used an alcohol swab and allowed it to air dry, while the DON stated the meter should be wiped with approved disinfecting wipes such as Sani-wipes or Clorox wipes and not alcohol. The manufacturer instructions listed validated bleach-based disinfecting wipes for the meter.
Staff failed to follow contact precaution requirements when entering a resident room posted for transmission-based precautions. A staff member was observed inside the room wearing only a KN95 mask, without the required gown and gloves, despite signage instructing use of these PPE items before entry. The unit manager confirmed that the expectation is for staff to wear a gown and gloves in such rooms, and the staff member acknowledged prior education that these PPE components are required. The facility’s written policy on transmission-based precautions also specifies that a gown and gloves must be worn when indicated by the type of isolation, indicating noncompliance with established procedures.
Housekeeping staff failed to use required PPE while cleaning a resident room under contact precautions and while moving between resident rooms. A resident with E. coli in the urine was on contact precautions, PPE was available outside the room, but HK entered and cleaned without donning PPE, then moved between rooms before being told by the HKS to put on a gown. The IP and Administrator stated staff were expected to use appropriate infection control practices and PPE when required.
A RN used the same BP cuff and monitor on two residents without disinfecting the equipment between uses, and later used it again on another resident without cleaning it before or after use. In a separate observation, a housekeeper/laundry aide moved a bin of soiled laundry through the clean side of the laundry room instead of using the soiled-laundry entrance, contrary to the facility's linen handling process.
An LPN touched tablets with a bare finger during medication preparation for two residents, then returned the tablets to the bottles. Staff also entered a resident’s room under neutropenic and contact precautions wearing only a mask on multiple occasions instead of the PPE indicated on the door signage and by the DON.
Infection control practices were not followed in a shared shower room when a commode seat had visible brown substance on it, and staff described a process where nursing cleaned the seat before housekeeping sanitized the commode. Staff also failed to follow EBP during wound care for a resident with a right hip wound who was under hospice care and moderately impaired for daily decisions; although a room sign indicated gloves and gowns were required for wound care, an LPN and RN provided the treatment without gowns.
Failure to Perform Hand Hygiene and Clean Insulin Pen Hubs During Medication Administration: An LPN failed to perform hand hygiene before donning gloves, after glove removal, between resident rooms, and before returning to the med cart while administering meds to two residents, one of whom was on contact precautions for MRSA. The LPN also pierced insulin pen septums without cleaning the pen hub and confirmed the missed hand hygiene and pen cleaning during interview.
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.