An LPN left medication cart P2 unlocked and unattended in a hallway, and the cart’s lock would not engage when she tried to secure it. The LPN said she had difficulty with the lock since the start of her shift but did not report it, and there was no shift-change communication about the issue. The DON later confirmed the cart remained unlocked when the key turned, and the Administrator stated he was aware the lock was not working.
Medication Left at Bedside Without Authorization A resident with intact cognition and occasional pain had a tube of diclofenac gel found on the bedside table while the resident was out of the room. There were no physician orders, care plan entries, IDT notes, or EHR assessments authorizing or assessing self-administration. The Activities Director removed the medication, and the DON confirmed there was no evidence the resident was approved to self-administer medications.
Expired and unlabeled medications were found in medication carts and medication rooms, along with loose pills that were not identifiable. An RN Unit Manager and an LPN observed loose tablets in carts, and multiple expired items were identified, including Sodium Chloride syringes, Chlorhex Gluconate solution, Milk of Magnesia, Pramoxine Hydrochloride, and Biofreeze Gel. An open bottle of Fish Oil was also found in the refrigerator without an open date. The DON stated that expired medications should be removed from stock and opened medications should be labeled with an open date.
A resident with intact cognition and diagnoses including dysphagia, GERD, HTN, and anxiety had a Soursop supplement left on the bedside table even though there was no documented IDT assessment or self-administration approval. The resident said he ordered and took the supplement himself, while an LPN later confirmed it was not supposed to be unattended at the bedside and found no order in the chart; a later provider order specified clinician-only administration.
A resident with dementia and moderate cognitive impairment had diclofenac sodium topical gel 1% left on the bedside table without a physician order or self-administration evaluation. The resident said he got the cream from his roommate and used it for knee pain. Staff, including an RN and the DON, confirmed the medication should not have been in the room and that the resident was not authorized to self-administer medications.
An unidentified white pill was left on the floor in a hallway for about 36 minutes and was passed by multiple nurses, CNAs, residents, the RN, the chef, and the Administrator without being removed. A CNA even wheeled a resident directly over the pill. When an RN finally retrieved it, the pill was identified as loratadine, but its origin could not be determined. The RN stated meds are administered on the hall and residents may take them outside their room, and the facility policy required meds to be kept in a locked med cart inaccessible to residents or others passing by.
Surveyors found that a medicated antifungal powder prescribed for a resident was left unattended on a television counter in the resident’s room instead of being stored in a locked treatment cart, as required by facility policy. The resident had multiple medical conditions and a care plan for pressure-ulcer risk but no assessment or provider order authorizing self-administration of medications. LPNs and the DON confirmed that the powder was an active, physician-prescribed treatment that should have been kept in the treatment cart and that no residents were approved to self-administer medications, while facility documentation showed other cognitively impaired and non-ambulatory residents on the same floor.
Unlocked Medication Cart with Pills Left on Top: A medication cart was observed unlocked in a hallway with a clear cup containing 2 white pills left on top and no staff present. An RN stated the pills were Baclofen and Tylenol for a resident and admitted she forgot to lock the cart after getting busy. The DON confirmed carts must be locked when staff step away, and the facility policy required drugs and biologicals to be stored in locked compartments accessible only to authorized personnel.
A resident with multiple chronic conditions and an active order for topical miconazole antifungal powder was found with two bottles of the medication on the bedside night table, one empty and one half-full, without any documented assessment, order, or care plan for self-administration. During observations and interviews, an RN, a CNA, and the DON all confirmed that powders are medications and that residents are not permitted to keep medications at bedside without a self-administration order and documented evaluation. Review of the EHR and facility policy showed that required assessments, documentation, and care planning for self-administration had not been completed, even though the medication was accessible in the resident’s room.
Unsecured Medication Cart Left Unattended: An RN left a medication cart unattended and unlocked while stepping into a resident room after preparing meds. The ADON later locked the cart. The ADON, RN, and DON all stated the cart must be locked when a nurse walks away, and the facility policy requires all drugs and biologicals to be stored in locked compartments.
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 August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.