Mock Annual Survey Audit for Nursing Homes

Internal mock survey rehearsal modeled on the CMS Long Term Care Survey Process to identify likely citations, deficiencies, and corrective actions before an annual survey.

Survey Scope and Facility Readiness

• Survey scope defined and units selected for walkthrough
• Current census, acuity, and resident sample list available
• Required policies, QAPI records, and recent plans of correction available for review
• Administrator, DON, and department leads notified and available for interview
• Entrance conference materials organized and accessible

Resident Rights, Care Planning, and Clinical Documentation

• Resident rights postings visible and current in common areas
• Care plans are individualized, current, and reflect assessed needs and interventions
• MDS, assessments, and physician orders are consistent with the medical record
• Behavioral interventions and psychotropic medication monitoring are documented when applicable
• Pain assessment and reassessment documentation present for residents with pain
• Weight loss, hydration, and nutrition risk triggers have documented interventions
• Falls, pressure injuries, and other adverse events have timely investigation and follow-up
• Resident grievances and complaint resolution documentation is complete

Infection Prevention and Control

• Hand hygiene supplies are available at point of care
• Staff demonstrate correct PPE selection and donning/doffing for isolation precautions
• Isolation signage is posted and matches resident precautions
• Cleaning and disinfection logs are current for shared equipment and high-touch surfaces
• Medication storage and treatment areas are clean, organized, and free of contamination risk
• Outbreak response supplies and escalation contacts are available
• Staff vaccination, training, and exposure follow-up records are current where required

Life Safety, Environment, and Emergency Preparedness

• Exits, corridors, and exit access are unobstructed and properly marked
• Fire doors close and latch properly when tested
• Fire extinguishers are accessible, mounted, and within inspection date
• Emergency lighting and exit signage are operational
• Oxygen storage, electrical cords, and other hazards are managed safely
• Emergency supplies, generator readiness, and disaster procedures are documented and accessible
• Housekeeping and maintenance issues do not create trip, slip, or infection hazards

Staffing, Training, and Competency

• Posted staffing schedule matches actual coverage for the survey period
• Required annual training is current for direct care and support staff
• Competency validation completed for high-risk tasks such as transfers, wound care, and medication assistance
• Agency or float staff orientation and supervision are documented
• Staff can describe escalation pathways for resident change in condition and emergencies

Findings, Corrective Actions, and Sign-Off

• Likely citations or deficiencies identified and categorized by severity
• Corrective action plan documented for each failed item
• Responsible owner and due date assigned for each corrective action
• Follow-up verification method defined for each corrective action
• Inspector summary and leadership sign-off completed