Failure to Provide Ordered Wound Care for Pressure Ulcers: A resident with DM, kidney disease, and bowel/bladder incontinence was readmitted with existing sacral/coccyx and left gluteal fold/ischial pressure ulcers, but the EMR lacked the hospital wound care orders and there was no documentation that ordered wound care was provided for days after readmission. The wounds later worsened with odor, slough, purulent drainage, and heavy bacterial growth, and the resident was transferred to the hospital where the sacral ulcer was found to be infected and required debridement and I&D.
Incomplete Skin Assessments and Missing Wound Care Documentation: A resident with a stage 2 PU had weekly skin evaluations that did not accurately identify the wound, and the TAR had multiple blank or missing entries for scheduled and PRN wound care across several months. The RN/RCM and DON acknowledged the skin checks were not charted correctly and that documentation should have been entered whenever an active wound care order existed.
A resident with a pressure ulcer had incomplete and conflicting Santyl orders. The initial order did not specify the application site, the EMAR showed Santyl applied to the groin and later the coccyx, and a later treatment order directed use on the coccyx only three times per week. Staff gave inconsistent accounts of whether the medication was for daily use, for pharmacy purposes, or for wound care, and the DON stated the order should have been updated and the site clearly identified.
A resident with pressure ulcers who was moderately cognitively impaired and dependent on staff for bed mobility did not receive documented consistent repositioning or pressure-reducing measures. The EHR included a wound report calling for aggressive offloading and a repositioning schedule, but there was no documentation of repositioning, and staff could not produce records to verify it. The resident was observed lying on his back during multiple checks, and the DON stated repositioning should have been documented in the resident care record but was not.
Failure to implement resident-specific pressure injury prevention interventions for a resident at risk for skin breakdown. The resident had a Braden score indicating risk, with dx including incontinence, foot drop, polyneuropathy, diabetes, and depression, but the care plan lacked prevention measures. The resident later developed a suspected SDTI to the left heel, and surveyors observed the heels resting on the bed despite a pillow being placed under the legs; the DON acknowledged no specific heel protection interventions were in place.
Failure to monitor and offload existing pressure injuries: A resident with encephalopathy, MI, and respiratory failure had stage 2 pressure ulcers to the tail bone and heel documented on admission, but no further wound monitoring was found. The care plan lacked repositioning and offloading interventions, and repeated observations showed the resident lying on their back with heels pressed on the bed and no pillows or other offloading devices in place. The resident said staff were not turning them or placing pillows under their feet, and the DON confirmed weekly assessments and pressure-reduction interventions were expected but did not occur.
Failure to assess, document, and treat pressure ulcers: Two residents had pressure injuries that were not properly monitored or documented. One resident with a pressure-related ear wound under oxygen tubing reported pain and said nursing had not assessed it; the chart had no wound assessment, provider notification, or treatment orders until surveyors identified the unstageable PU. Another resident with a coccyx PU had multiple blank TAR entries for ordered wound care, and leadership confirmed the missing documentation meant the care was not charted.
A resident with quadriplegia and significant pressure ulcers had an order for an alternating pressure-relieving mattress, but repeated observations showed the mattress remained on Static and locked instead of Alternating. Although the TAR was initialed as completed, staff interviews showed they were only checking that the mattress was plugged in and inflated, and several staff believed the settings were already programmed or could not be changed.
Failure to document and care plan a pressure injury: A resident with cerebral palsy, quadriplegia, DM, impaired cognition, and dependence for mobility developed an open area on the buttocks/thigh that progressed to a stage 3 PI. Nursing notes repeatedly described the wound as open or improving but often omitted measurements, depth, and staging, and the first measurement was not recorded until weeks after the wound was first noted. The resident’s care plan listed general skin risk but did not include the PI or specific interventions, and staff interviews confirmed the wound should have had an acute care plan and wound assessment opened when first identified.
A resident with paraplegia and mild PI risk had a physician order for a weekly foam offloading dressing to the left heel and a care plan and facility policy requiring weekly skin assessments and CNA reporting of skin changes. The dressing on the heel remained in place far beyond the ordered change interval, with an LPN admitting to peeling it back, briefly inspecting, and reapplying the same dressing without changing it or checking the date. A CNA later noticed dried fluid on the resident’s sock and alerted an RN, who found the dressing dated several weeks earlier and, upon removal, discovered an unstageable PI on the left heel that required debridement.
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 October 8, 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.