A resident who needed ADL assistance was left overnight in street clothes and a soiled brief after night staff misread the care plan and assumed that not disturbing sleep meant no bedtime hygiene, clothing change, or evening toileting was needed. The resident and morning staff reported she was found wet and still dressed in the prior day’s clothing, while the CNA claimed care had been provided.
Two residents did not receive scheduled bathing and showering services needed for ADL care and hygiene. One resident had multiple missed bed baths with only one documented bath out of five scheduled, and another resident had missed showers with only one documented shower out of four scheduled. The acting Administrator and interim DON acknowledged the documentation and missed care.
A resident who had capacity reported she had not received a shower in three weeks despite expecting showers twice weekly and stated her hair was greasy and she could not care for it herself. The care plan identified a need for substantial/maximal assistance with bathing, but it was not updated to reflect her preference for showers, and the bathing record showed she was receiving bed baths instead of showers; staff could not confirm that she had refused the showers.
Failure to provide daily ambulation assistance after therapy discharge. A resident who had been discharged from PT with orders for daily walking with nursing assistance and a RW was documented as walking only once over three months. Staff interviews confirmed nursing staff were expected to assist with daily ambulation, but CNAs reported they did not regularly walk the resident and had not seen her walk.
A resident who could not complete ADLs independently did not receive scheduled bathing assistance as ordered. Her record showed she preferred bed baths, but the bathing log reflected multiple missed bath intervals, and an RN consultant confirmed that a bath or documented refusal was not recorded.
Failure to provide needed nail care: A resident who was dependent for ADLs stated her nails needed to be cut, and staff observed the nails to be long and in need of filing on repeated checks. The DON said Activities usually provided nail care and confirmed that this care should have been provided, but did not confirm the nails had been trimmed until a later observation showed them appearing trimmed and filed.
Failure to provide feeding assistance to dependent residents. A resident was observed with a cold breakfast tray and no feeding help despite a tray ticket showing assist needed, an LPN confirmed another resident had not been assisted and believed the order was old, and a third resident was found with a full lunch tray at bedside with no help provided. The resident’s daughter reported repeated instances of breakfast trays left untouched and cold, and the care plan called for partial/moderate assist with eating.
A resident who ate slowly and was observed falling asleep during lunch did not receive cueing or meal assistance while staff removed the tray after partial intake. Staff interviews confirmed aides typically left the tray because the resident took a long time to eat, and the DON acknowledged the resident did not receive meal assistance and had experienced weight loss.
A resident who preferred help with shaving was observed with visible facial hair and stated she does not always receive this assistance. The DON confirmed the resident had visible facial hair and said staff would help her get shaved.
Failure to provide needed ADL hygiene and bathing care for two residents. One resident was observed with a dirty face, neck, and hands, soiled bedding, long untrimmed fingernails, and scratches behind the ear, while the resident’s wife reported she had to clean him and trim his nails. Another resident stated he had gone several days without a shower, and records showed only one bed bath with no refusals despite a shower schedule and a care plan for extensive assist with bathing.
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.