A CMA crushed and gave a resident potassium chloride ER and enteric-coated aspirin in applesauce, even though both medications were identified by the pharmacy vendor and an RN as not to be crushed. The EMAR did not indicate crushed medications, the DON said the resident profile listed crushed meds but that information did not flow to the MAR, and the staff member’s competency checklist did not address crushing medications.
Staff failed to administer insulin as ordered for two residents and repeatedly held or reduced insulin doses without notifying the physician. One resident with severe cognitive impairment had multiple Lantus and Novolog doses held, while another resident with diabetes and intact cognition had repeated insulin Aspart doses held or cut in half per nursing judgment. Interviews showed staff were given inconsistent direction about whether insulin could be held without contacting the MD, despite the facility policy requiring medications to be given according to physician orders.
An LPN administered Novolog flexpen insulin to two residents with diabetes without properly priming the pen and removed the needle too soon after injection. Observations showed the LPN dialed the pen to 1 unit and pushed the button while holding it horizontally before setting the ordered dose, then removed the needle within only a few seconds. The ADON stated the pen should be primed before each injection and held in place for 30 seconds, while the manufacturer instructions required priming and holding the dose knob in for at least 6 seconds.
A facility had significant medication errors involving controlled substances and insulin administration. An LPN removed alprazolam from one resident’s supply and attempted to give it to two other residents who did not have orders for it, with one resident receiving the medication and another refusing. In separate events, a CNA/CMA dispensed oxycodone from two different residents’ medication cards to give one resident the correct dose, and an RN administered Lantus without priming the insulin pen before giving the ordered units.
A resident with anxiety, restless leg syndrome, and acute pain repeatedly received evening meds late, with scheduled 7:00 PM doses often not given until later in the evening and the resident reporting she sometimes stayed up until after midnight because of delayed meds and cares. In a separate event, an RN preparing Novolog for a resident with DM and dementia combined the insulin pen prime and dose into one step, setting the pen to 5 units instead of following the manufacturer’s separate priming and dosing instructions.
A resident with anxiety disorder and intact cognition missed multiple doses of alprazolam when the medication ran out and was not reordered in time. MAR entries and nursing notes showed the doses were marked as on order or out of medication, and staff interviews confirmed the pharmacy had not received a refill request and emergency stock was not used to bridge the gap.
A resident with Huntington’s disease and methadone therapy experienced a medication-related emergency after the facility did not clarify the Narcan order on admission, did not have Narcan immediately available, and had staff who lacked access and training for the Medbank. The resident later became cyanotic and unresponsive, was transferred to the ER, and the hospital documented acute respiratory failure and opioid intoxication. The record also showed inaccurate measurement of titrated liquid methadone doses, with staff using a syringe that could not accurately measure odd mL doses.
Medication Error Caused Resident Sedation and Hospitalization: A resident with HF, DM, and dementia became unresponsive after receiving another resident's meds, including amoxicillin, quetiapine, and levetiracetam. Staff reported the CMA prepared meds from memory without using the MAR, and the resident was later hospitalized with significant sedation, low BP, and low HR. The resident said she remained groggy and not back to baseline after the event.
Significant insulin administration errors occurred when ordered insulin was not given or not documented as given for multiple residents with diabetes and other serious conditions. A nurse working an unfamiliar hall acknowledged forgetting insulin doses while residents had elevated blood sugars, including repeated HI readings for one resident, and the MARs showed several scheduled basal and sliding-scale insulin orders were left incomplete without progress notes explaining why.
Two residents missed their scheduled evening medication pass when meds were found in envelopes stapled or taped to their bubble packs, yet the MARs showed the doses as administered. One resident had no cognitive impairment and diagnoses including renal insufficiency and malnutrition; the other had severe cognitive impairment with diagnoses including dementia and a blood clot history. Staff and the DON confirmed the missed doses, and one resident’s regimen included Eliquis, a high-risk medication.
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 October 8, 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.