A mock survey that everyone passes was not a survey. Assign an outsider — a peer administrator or corporate clinician — who has no stake in the result.
Follow the real process: entrance conference, initial pool selection, resident and family interviews, kitchen and medication pass observation, closing conference.
Write findings in regulatory language with the tag number attached. Vague notes do not convert into plans of correction.
Schedule the re-check thirty days out and treat missed corrections as a leadership performance issue, not a paperwork issue.