A resident with COPD, respiratory failure with hypoxia, and sleep apnea had nebulizer treatments documented as complete even though the nebulizer cup still contained medication during observations. Staff found the nebulizer left assembled on the resident’s end table, and an RN and LPN confirmed medication remained in the cup. A self-administration assessment stated the resident was not safe to self-administer inhalants without supervision, but the record was not updated to reflect that change, and the facility’s nebulizer policy required staff to remain with the resident and clean the equipment after use.
A resident with MS, HTN, neurogenic bladder, COPD, and hyperlipidemia did not receive scheduled 7:00 a.m. medications, and the MAR showed blank boxes for multiple ordered meds including lisinopril, omeprazole, trimethoprim, oxybutynin, baclofen, and gabapentin. The DON confirmed the meds were not administered within the allowable time window and stated medications are expected to be given as ordered.
A resident with intact cognition and diagnoses including a right femur fracture and diabetes received enoxaparin injections ordered for DVT prevention after hip arthroplasty. The MAR listed a calculated end date based on the dispensed quantity, but an RN did not contact the PCP to verify the stop date and no verbal order to stop the med was obtained. The DON stated the end date for enoxaparin should be verified with the provider, and the consulting pharmacist noted that no refills does not always mean the med should be discontinued.
Medication labels for multiple residents were found without an expiration date or beyond use date. An ADON, LPNs, RN, and pharmacists confirmed that labels from both pharmacies did not clearly show when medications should be discarded, and staff were relying on fill dates or general refill timing instead of a visible expiration or BUD on the label.
Surveyors found that staff did not consistently follow a systematic process to account for controlled medications in the emergency kit and for residents’ home medications stored in the medication room. An RN described using breakaway locks, a binder of lock numbers, and pharmacy usage forms when removing controlled drugs from the e‑kit, but there was no evidence of the every‑shift controlled substance inventory required by policy, and the pharmacist stated the facility should be completing such inventories. Staff, including an RN, an LPN, and a TMA, gave differing accounts of how home medications were handled, often involving placing medications in bags and cabinets, sometimes unlocked, without a standardized method to document all medications and pill counts. These practices did not align with facility policies requiring shift‑to‑shift controlled substance counts by two licensed nurses and proper documentation of medications brought in by residents or responsible parties.
A resident with multiple chronic conditions had provider orders for daily cranberry capsules for UTI prophylaxis and daily lactobacillus for diarrhea, but the facility failed to administer numerous doses over an extended period. MARs showed repeated missed doses of both medications, with nursing notes documenting that the medications were on order, not available, or awaiting pharmacy or house stock delivery. An LPN described the process for documenting unavailable medications and contacting the pharmacy, and the DON described the house stock request process and defined missed doses as medication errors. The NP reported she was not notified about the missed doses, despite expecting to be contacted when medications were not administered as ordered.
A resident with chronic pain, an amputation, and PTSD was ordered morphine IR 15 mg QID with PRN 7.5 mg doses, but staff failed to secure a timely refill when the supply ran low, resulting in multiple missed scheduled doses and only a single partial PRN dose over roughly a day. A day‑shift RN recognized the impending shortage but did not obtain a new prescription, and an on‑call NP later signed an electronic order without confirming pharmacy receipt, declined to resend it that night, and did not order alternative pain control or monitoring for opioid withdrawal. The resident reported 10/10 pain, remained in bed, had decreased appetite, and increased anxiety, while his spouse observed sweating, confusion, and functional decline, and documentation showed no comprehensive assessment for withdrawal. Review of narcotic records revealed incomplete controlled substance sheets lacking RX numbers, prescriber names, and directions, and discrepancies between documented quantities received and pharmacy packing slips for morphine, compromising accurate tracking and availability of the opioid.
A resident with gas gangrene and a foot ulcer was discharged from the hospital with an order for amoxicillin-pot clavulanate to be given twice daily starting on the day of admission and stopping on a specified later date. Although the facility’s physician order matched the hospital discharge order, the MAR was transcribed with a start date one day later, so the medication did not populate for administration until the following evening. As a result, the resident missed two ordered doses. The pharmacist, RN staff, NP, and DON all confirmed that medications are expected to start on the day of admission unless a different start date is ordered, that the first dose was not given until the next day’s evening shift, and that the order had not been transcribed accurately in accordance with facility policy.
The facility did not ensure accurate reconciliation and secure destruction of controlled substances, resulting in the diversion of narcotic medications by a former employee. Staff interviews revealed that medication destruction logs were incomplete or missing, and required witnessing and documentation procedures were not consistently followed, allowing for the loss of medications prescribed to multiple discharged residents.
A resident with a diagnosed eye infection did not receive prescribed oral and ophthalmic antibiotics on the day they were ordered, despite provider instructions for immediate administration. Medication records and staff interviews confirmed the delay, and the error was not communicated to the resident or their representative. Facility policy required timely administration and documentation of medication errors, but the process was not followed, and leadership was unaware of the incident until identified by surveyors.
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