A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
A resident with COPD, anxiety disorder, malnutrition, and a history of alcohol abuse in remission, who was receiving benzodiazepine anti‑anxiety medication and had no order or care plan allowance for alcohol, was found multiple times to have consumed alcohol in the facility. CNAs and LPNs discovered empty and full alcohol bottles in the resident’s room and observed the resident appearing drunk, groggy, confused, lethargic, and slurring words, with noted balance and behavioral changes. The APRN documented increased drowsiness, equilibrium concerns, and later confusion and auditory disturbances, and held the anti‑anxiety medication after learning of intoxication. The DON and Administrator reported that the resident identified a CNA as the source of the alcohol, and the CNA admitted to bringing alcohol to the resident on two occasions, resulting in intoxication within the facility, contrary to the resident’s orders and care plan.
Surveyors found that the facility failed to follow physician orders for PICC line dressing changes, wound care, and catheter care for two residents. One resident with osteomyelitis, pressure ulcers, and an indwelling catheter had multiple missing entries on the TAR for ordered PICC line dressing changes, daily pressure ulcer treatments to the heel and coccyx, and catheter care every shift, with the DON confirming that blank TAR blocks indicated treatments were not completed. Another resident with a PICC line for antibiotic therapy had an order for weekly dressing changes, but the dressing was not changed as scheduled, the PICC site was left uncovered for several minutes during medication administration, and an LPN admitted initialing the TAR to indicate a dressing change that she had not performed, while the TN and APN confirmed the order required adherence to the weekly schedule.
Two residents with significant cognitive and neuromuscular/orthopedic conditions experienced falls when staff did not follow care-planned assistance and supervision requirements. One resident, care-planned for two-person assist with bed mobility, transfers, and personal hygiene, was found on the floor after a CNA attempted incontinent care alone. Another resident, care-planned for staff assistance with dressing and two-person assist for transfers with a slide board, was left seated at the edge of the bed and told to dress themself; the resident fell while unattended and was later found on the floor wearing a C-collar. CNAs reported relying on the electronic care plan/Kardex for instructions, but one CNA described unclear and brief initial training on accessing the system, while leadership stated CNAs were expected to verify care needs in the electronic care plan before each care episode.
A resident with schizophrenia, anxiety disorder, thyroid disorder, hyponatremia, and other conditions was admitted on multiple psychotropic and medical medications, but from admission until elopement the next day received only one documented dose of a hyponatremia medication. The care plan called for administration and monitoring of anxiety and schizophrenia medications, yet the MAR showed 15 missed doses of mood stabilizers, antipsychotics, thyroid and hypertension medications, an NSAID, a vitamin, and a medication for extrapyramidal symptoms, with reasons such as refusal and medications unavailable. An LPN reported medications were not yet delivered, another LPN stated medications arrived after the evening med pass and was unsure about using the Pyxis, while the drug manifest showed several medications were received that evening and leadership confirmed some psychotropic and anxiety medications were available in the Pyxis and that facility policy required administration within one hour of scheduled times.
A resident with moderate cognitive impairment, behavioral symptoms, a history of falls, and an active PRN pain medication order returned from the hospital at night and repeatedly requested pain medication for head pain. A CNA reported the requests multiple times to the only LPN on duty, who had the keys to all med carts, but the LPN did not assess the resident on that hall or administer any pain medication, stating that another LPN (who was not present or on the staffing log) was supposed to pass meds there. Review of the eMAR and staffing records confirmed that no pain medication was given during this period despite the resident’s repeated requests and an active PRN order, constituting a failure to provide ordered and requested pain management.
A resident with a recent abdominal surgery was admitted with staples in place and severe pain, but the facility did not obtain or implement physician orders for wound care or assessment. Nursing staff failed to perform or document wound assessments, did not notify a provider despite significant drainage and pain, and removed surgical staples without confirming the wound's readiness. This led to wound dehiscence, rehospitalization, and emergency surgery.
A resident with a recent abdominal surgery and PEG tube was given a regular meal instead of the prescribed clear liquid diet and tube feedings, due to miscommunication and errors in transcribing dietary orders between nursing and dietary staff. The resident consumed part of the inappropriate meal, experienced ongoing nausea and vomiting, and was not adequately assessed or monitored for changes in condition, ultimately resulting in the resident being found unresponsive.
A resident with severe cognitive impairment and incontinence was not checked or changed for an extended period, resulting in saturated clothing and a soiled brief. Despite facility policy and staff training requiring checks every two hours, CNAs admitted the resident was overlooked due to other duties. Nursing staff interviews confirmed expectations for regular incontinence care and repositioning were not met.
A resident with orders for a benzodiazepine and an opioid pain medication, which required at least a two-hour separation between doses, received both medications within minutes of each other on multiple occasions. Multiple LPNs administered the medications together, despite clear orders and facility policy requiring separation, and facility leadership confirmed that staff were expected to follow these orders.
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.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account