Two residents did not receive care according to physician orders and professional standards. One resident with a lower extremity venous/arterial ulcer and lymphedema had wound care performed by the ADON and an RN without use of ordered skin prep to the peri-wound area and without application of ABD pads, even though the existing dressing removed from the leg included heavily saturated ABD pads and the CPO specified Dakin’s, skin prep, silver sulfadiazine, adaptic, ABD, and Kerlix every shift. Another resident with chronic pain syndrome, cervical spinal stenosis, and alcoholic polyneuropathy, who was cognitively intact and independent with ADLs, had a standing order for morphine ER 30 mg TID but had multiple scheduled doses not administered when the facility ran out of the medication and did not have the ordered dose available; MAR review and staff interviews confirmed missed doses and lack of timely availability of the prescribed morphine.
The facility failed to follow its alcohol policy by serving alcoholic beverages during a weekly happy hour without physician orders for two residents. One resident with multiple sclerosis, hypertension, osteoarthritis, and depression, who was cognitively intact and required extensive ADL assistance, reported drinking alcohol at happy hour, had signed a form allowing alcohol if the MD agreed, but had no corresponding order or care plan focus for alcohol use. Another resident with chronic respiratory failure, hypertension, mild dementia, depression, and a documented history of alcohol abuse in remission also reported weekly alcohol use at happy hour, had consented to alcohol on admission forms, and had a psychosocial care plan noting alcohol dependency history, yet had no MD order authorizing alcohol. Staff, including the AD and SSD, confirmed that residents were offered up to two alcoholic drinks based on preference, that no list of authorized residents was maintained, and that alcohol consumption was not tracked, despite policies requiring MD orders and pharmacist review for alcohol administration.
A resident with a history of falls, fractures, and significant mobility impairment experienced an unwitnessed fall from bed, which had been left in a high position despite care-plan interventions requiring it to be kept low with a fall mat. An RN found the resident on the floor, initiated neuro checks, and documented elevated BP readings and pain but did not complete or document a thorough head-to-toe assessment before moving the resident back to bed, and did not promptly notify the MD, hospice, or the resident’s representative. Hospice was contacted several hours later due to rising BP and severe pain; a hospice RN then assessed the resident, notified the on-call MD, and obtained an order to transfer the resident to the hospital, where imaging revealed multiple fractures and a scalp contusion. Staff interviews and facility policy confirmed that standard practice required immediate RN assessment prior to moving a fallen resident, timely MD and family notification, and adherence to fall-prevention interventions, all of which were not followed in this case.
Missed Blood Sugar Monitoring and Failure to Notify Physician of High Glucose: Staff failed to consistently check a resident’s blood glucose as ordered and did not notify the physician when a reading was above the ordered threshold. The resident had diabetes with ketoacidosis and CKD, was cognitively intact, and had several missed or undocumented blood sugar checks. Staff also documented the resident as unavailable or refusing without further explanation, and there was no documentation that the physician was notified of the elevated glucose result.
Failure to Enter and Follow Post-Orthopedic Dressing Orders: A resident with a right ankle fracture returned from an orthopedic visit with instructions for dressing changes, but the orders were not entered into the EMR and the dressing was not changed as directed. The resident reported the dressing remained unchanged until she alerted staff, and the wound care order was not initiated until later during the survey.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with type 2 DM, CKD, and severe cognitive impairment had a blood sugar of 439 mg/dL, after which the physician ordered 5 units of Lantus SC daily. Following administration of this new long-acting insulin, there was no documented blood glucose monitoring to assess treatment effectiveness or to detect potential side effects. The DON confirmed that there was no follow-up re-evaluation or documentation of the incident or the order in the resident’s EHR, despite the known risk of hypoglycemia associated with Lantus.
A resident with chronic pain, osteoarthritis, contractures, and lower leg wounds had orders for scheduled and PRN oxycodone, with a care plan directing that pain medications be administered as ordered. Over several days, multiple doses of the resident’s scheduled immediate-release oxycodone were not given, with documentation indicating the drug was on order or not on hand and no documented notification to the provider when it was unavailable. The resident reported missing pain doses several times, experiencing increased pain and withdrawal-like symptoms, and being told staff were waiting for the pharmacy. Staff interviews revealed inconsistent understanding and execution of the medication re-ordering and provider-notification process, and facility leadership later acknowledged that one missed dose occurred despite adequate stock and without documented reason or provider contact.
A resident with a history of hypertension experienced a fall with head injury and subsequently had persistently elevated blood pressure readings for over four hours. Despite repeated high BP measurements, the physician was not notified in a timely manner and no intervention was implemented until hours later, contrary to facility policy and professional standards. The resident was eventually transferred to the hospital with critically high blood pressure.
A resident with an ileostomy did not receive ostomy care according to physician orders and professional standards. The resident often changed her own appliance without formal training, and staff inconsistently followed care protocols, including not using dedicated equipment, not applying prescribed treatments, and failing to perform proper hand hygiene. The resident's skin was observed to be red and inflamed, and staff interviews confirmed lapses in following established procedures.
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