A resident receiving IV meropenem for an abdominal abscess after surgery missed 27 ordered doses when the antibiotic was stopped without explanation and later restarted after the ID office called the facility. The resident also did not receive ordered weekly CBC, CMP, and CRP labs while on IV antibiotics, and the DON stated the labs had not been completed until the ID office reported they were missing.
The facility failed to maintain oversight of antibiotic use and infection criteria. A review of the infection surveillance program showed multiple infections listed as unknown, infections without documentation that McGeer's criteria were met, and multiple antibiotic orders for residents with no documented signs or symptoms. The IP stated the program lacked required components and that the facility had identified the same concerns in its antibiotic stewardship oversight.
Incomplete infection surveillance and antibiotic stewardship monitoring were identified. The facility’s logs did not consistently track residents with infections, infection type and location, causative organisms, or IP follow-up actions, and the IP stated surveillance data was not consistently tracked or analyzed after the prior IP’s termination. Review of antibiotic records showed residents on antibiotics were not routinely monitored for appropriateness, culture and sensitivity results, duration, or efforts to reduce unnecessary antibiotic use, and the DON acknowledged there was no active antibiotic stewardship committee.
A resident admitted with enterococcal infection and sepsis had antibiotic orders that did not match the hospital transfer instructions, which called for IV ampicillin. The MAR instead showed oral amoxicillin and later IV daptomycin, with no cultures available to confirm sensitivity or appropriateness. Lab results showed elevated neutrophils, but there was no documentation that the practitioner acknowledged the abnormal value. Nursing notes also documented cloudy, thick urine and a later urine culture with Citrobacter and Candida tropicalis, while the DON stated cultures and antibiotic stewardship documentation could not be found.
Antibiotic stewardship and infection criteria were not followed for 4 residents who received antibiotics for UTIs that did not meet McGeer criteria. The IP could not locate supporting UA, culture, or organism documentation for Macrobid, Cipro, levofloxacin, and Bactrim DS use, and stated there was no urine dipstick policy or McGeer procedure available; the computer program flagged criteria, but the NP decided whether antibiotics were stopped.
Failure to Monitor Antibiotic Use and Document Stop Dates: A resident with dementia, AKI, COPD, and a history of UTI received multiple antibiotic orders and changes, including prophylactic antibiotics with no stop date, while nursing and physician notes did not document UTI monitoring or antibiotic review. The resident denied urinary symptoms, had diarrhea during treatment, and no UA or urine culture was ordered after admission despite the facility’s antibiotic stewardship policy calling for diagnostic testing and antibiotic orders with an indication and stop date.
Failure to Monitor and Track Antibiotic Use: The facility did not operationalize a comprehensive antibiotic stewardship program or consistently use McGeer criteria to track antibiotic therapy. The IC RN reported that the monthly line list and summary did not show whether infections met criteria or whether treatment was appropriate, and forms were not completed for residents admitted on antimicrobial therapy. One resident received Azithromycin for a URI that the McGeer form showed did not meet treatment criteria, and the concern was not addressed with the HCP. Another resident was admitted with a UTI and received an antibiotic despite no growth on culture, with no McGeer form completed.
Failure to Operate an Effective Antibiotic Stewardship Program: The facility did not consistently ensure infection criteria were met before antibiotics were used for multiple residents. Record review showed several antibiotic starts for UTI, pneumonia, cellulitis, and CAUTI with missing or conflicting documentation for symptoms, diagnostics, cultures, and McGeer’s Criteria, including cases where hospice declined testing or urine studies were negative. Interviews with the interim infection preventionist and acting DON confirmed ongoing problems with antibiotic stewardship documentation and oversight.
The facility failed to maintain a continuous Antibiotic Stewardship Program as required by its policy and CDC core elements, including monitoring antibiotic use, tracking resistance, and following McGeer’s criteria and diagnostic testing protocols before initiating antibiotics. The written policy required complete antibiotic orders with indication and stop dates and tracking of adherence to clinical documentation and culture practices. However, during a review with the DON and a corporate nurse, surveyors found that documentation for the Antibiotic Stewardship Program was missing for several months, and an internal audit had already identified inadequate documentation, indicating the program was not properly implemented and had the potential to affect all residents.
Failure to Document and Administer Ordered Antibiotic: A resident with Parkinson's disease, DM, and PVD was treated for cellulitis of the right lower extremity, but cephalexin doses were repeatedly not documented as administered on the MAR. The physician ordered cephalexin 500 mg TID, yet multiple scheduled doses were missing across the treatment period, and the facility could not verify that all doses were actually given.
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.