A resident with dementia, schizoaffective disorder, severe cognitive impairment, and a history of aggressive and resident-to-resident altercations was involved in an unwitnessed physical altercation with another resident, resulting in a fall, facial laceration, and a closed fracture. The resident was sent to the hospital for evaluation and then readmitted, but the hospital discharge paperwork did not include the expected psychiatric evaluation or harm clearance. The admitting RN did not obtain psychiatric clearance or a no-harm letter at the time of readmission, and the resident was not evaluated by a psychiatric provider until nearly eight hours later. Facility leadership acknowledged that the readmitting RN was responsible for identifying missing documentation and that there was no specific policy for psychiatric evaluations or 1:1 assignments following physical altercations.
A resident with a history of kidney transplant was readmitted from the hospital with an order for Tacrolimus XR totaling 6 mg daily. During medication reconciliation, an RN used the prior EMR orders and changed the number of tablets from one to six but failed to adjust the tablet strength from 4 mg to 1 mg, creating an EMR order for six 4 mg tablets (24 mg total). The required second reconciliation by another RN was not completed, and an LPN administered the dose as entered, relying on the assumption that two supervisors had verified the orders and that the medication’s presence in the cart indicated correctness. This sequence of transcription error and missed double-check resulted in the resident receiving a fourfold overdose of Tacrolimus.
A resident with CHF, respiratory failure, pulmonary edema, dementia, severe edema, incontinence, and dependence for bed mobility and transfers was repeatedly scored as only mildly at risk for pressure injuries on Braden evaluations completed by an LPN. Therapy and nursing documentation described the resident as bedfast most of the time, incontinent, requiring a mechanical lift or stander with assist of two, and having +3 pitting edema with some open areas, which supported a much lower Braden score and high risk status. The care plan carried over outdated interventions (assist of one for transfers) and did not fully reflect current PT/OT recommendations or the resident’s true functional status. Facility leadership confirmed that Braden tools completed by LPNs were not reviewed or co-signed by an RN, despite state practice standards that LPNs cannot independently perform nursing assessments, and the ADNS later acknowledged that the Braden scores were inaccurate and understated the resident’s risk.
A resident with severe cognitive impairment, multiple psychiatric and medical diagnoses, and dependence for ADLs and transfers fell forward from a wheelchair while an LPN was repositioning the resident, resulting in a forehead laceration requiring sutures. Although the care plan identified fall risk and altered mobility, the facility’s post-fall documentation did not include staff witness statements or a root cause analysis. The DON confirmed that no staff statements or analysis of the cause of the fall were available, despite facility policy requiring written witness documentation and a root cause analysis after witnessed incidents.
A resident with MS, paraplegia, dementia, and depression experienced an acute change in mental status, including word-finding difficulty and dysarthric speech. An LPN notified the supervisor RN, who initially felt the resident was at baseline, but later another LPN confirmed the change in condition. The APRN, contacted via AV technology, identified the situation as an acute, critical problem, agreed with hospital transfer, and documented that EMS had been activated. However, EMS records showed that dispatch was not contacted until 41 minutes after the APRN’s note. When EMS arrived, the resident was obtunded with very low systolic BP, requiring IV fluids and Narcan before transport, demonstrating a delay in timely EMS activation following a significant change in condition.
A resident with vascular dementia, chronic A-fib, muscle weakness, and a care plan requiring one-person assist for transfers stumbled during a transfer to bed and struck the hip on a side rail. The NA completing the transfer did not report the incident to the nurse at the time, stating the resident did not fall, had no pain complaints, and was asleep at end-of-shift rounds. The next morning, staff noted hip discoloration and pain, notified the APRN, and sent the resident to the hospital. The facility could not provide a policy on incident reporting for surveyor review.
A resident with COPD, seizures, bradycardia, visual impairment, weakness, and a cognitive communication deficit, who required substantial assistance for transfers and used a wheelchair, experienced an unresponsive episode while seated on a bench in the supervised smoking area. After a NA reported the resident might not be breathing, an RN assessed the resident as breathing but nonverbal with abnormal skin color, then left the resident with two NAs and instructed them not to move the resident while she went inside to call a code and EMS, leaving no licensed nurse at the scene. During her absence, an LPN arrived, found the resident leaning forward and responsive, and, without RN direction, assisted with transferring the resident to a wheelchair and transporting the resident inside, before the RN’s assessment was completed. EMS later documented that staff could not provide a clear, consistent account of the incident, including whether a fall or head strike occurred, reflecting that the resident was moved and the event was not fully or accurately assessed and documented in accordance with facility policies for change in condition and accidents.
A resident with multiple cardiac conditions and an active DNR order, including RN pronouncement authority, was last seen in a recliner and later found on the floor after walking unassisted to use a commode. A CNA discovered the resident on the floor and notified nursing staff; an RN assessed the resident, who was moaning with minimal verbal response, and prepared to call EMS for transfer. Shortly thereafter, an LPN found the resident unresponsive with no pulse or respirations, left the room to get a crash cart and notify the RN, leaving the pulseless, apneic resident alone with two CNAs, and then returned and provided rescue breaths for about two minutes despite the DNR. The RN pronounced death without EMS on scene, and EMS was not contacted until roughly 30–38 minutes after the resident was found on the floor, contrary to facility policy requiring a 911 call for unanticipated deaths when EMS or hospice had not assumed care.
A resident with dementia, anxiety, rheumatoid arthritis, and moderate cognitive impairment required substantial/maximal assistance for transfers and was wheelchair dependent. The care plan contained conflicting directions, listing both one- and two-person assist for transfers, while the physician’s order and NA care card specified one-person assist with a gait belt. In practice, some RNs and an NA believed or used a mechanical (Hoyer) lift for transfers due to the resident’s leg weakness, but there was no corresponding physician order, care plan entry, or NA care card direction for lift use. The DON was unaware that a mechanical lift was being used and acknowledged that any change in transfer status should have been supported by an RN or therapy assessment and updates to orders and the care plan, which had not occurred.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a prior wrist fracture was initially assessed as not at risk to low fall risk, but the care plan documented fall risk due to cognitive impairment and generalized weakness, with interventions such as call light within reach and assistance with transfers. A subsequent quarterly MDS showed severely impaired cognition (BIMS 3) and need for substantial assistance with mobility, yet no Fall Risk Evaluation was completed for several months, including around the time of the quarterly assessment. The resident later experienced a fall, was found on the floor with a reddened hip and, later, a bump on the head and inability to move the neck, and was transferred to the ED, where an acute displaced type II odontoid fracture was diagnosed. The DON reported that Fall Risk Evaluations were expected on admission, quarterly, and with changes in condition, but no specific policy on Fall Risk Evaluations was available.
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