A resident who was cognitively intact had unlabeled hydrocortisone cream and antifungal powder at the bedside and said staff had given them to him for PRN use. The record lacked provider orders and any self-administration assessment for the topical medications, and staff gave conflicting accounts about whether the resident was allowed to keep and use them. The care plan also did not address bedside storage or self-administration of these medications.
A resident with anemia, MS, and a seizure disorder was found with Diclofenac cream, Biotin mouth wash, and Systane eye drops left on the bedside table even though the SAM evaluation and care plan stated the resident could not self-administer medications or keep them at bedside. The active order summary had no bedside-medication orders, and an LPN and RN both acknowledged the medications should not have been left in the room.
Failure to complete and follow self-administration assessments for bedside meds. A resident with asthma had an inhaler kept at bedside even though the SAM eval said she no longer self-administered meds, and staff gave conflicting accounts about the assessment. Another resident with TBI, DM, and asthma had tablets/capsules repeatedly left at bedside despite updated SAM findings that only certain meds could remain there and other meds were to be administered by nursing, with no matching provider communication or care plan update. A third resident with hepatic encephalopathy, HF, and DM had nasal spray at bedside even though the SAM eval said she was not reliably safe to self-administer and no bedside-med order was shown.
Unassessed Bedside Eye Drops Kept in Resident Room: A cognitively intact resident with multiple chronic conditions had two unlabeled eye drop bottles, Systane Complete and ketotifen fumarate, observed unsecured on his bedside table. The resident’s SAM assessment indicated he did not want to self-administer medications, his care plan did not address bedside storage or self-administration of the eye drops, and the medical record lacked provider orders or authorization for bedside keeping. Staff stated the drops may have come from home and were being given at the resident’s request, while the DON stated a completed assessment and provider order were required before medications could be kept in the room.
The facility failed to complete SAM assessments and obtain provider orders before leaving medications at the bedside for two cognitively intact residents. Both residents had SAM inquiry forms indicating they did not want to self-administer medications, yet labeled antifungal medications were observed in their rooms and their orders lacked SAM authorization. An LPN stated bedside medications require a doctor’s order and assessment, and the DON confirmed neither resident had a SAM assessment.
Medications were left at a resident’s bedside without a completed SAM assessment or physician order. The resident had moderate cognitive impairment on admission and diagnoses including UTI and COPD, but the EMR lacked a SAM assessment, bedside medication orders, and a related care plan. Surveyors observed nystatin cream, refresh eye drops, and later diclofenac cream in a basin in the resident’s room, while an LPN, RN, and DON confirmed the assessment was expected before medications were left in the room.
A resident with COPD and RA was assessed as unable to self-administer medications, yet staff observed the resident using an albuterol nebulizer treatment at the bedside. The resident stated staff set up the nebulizer and the resident turned it on, while a TMA said she set it up and later returned to clean it. The DON confirmed there was no current order for the resident to self-administer medications.
Failure to Assess Self-Administration of Medication: A cognitively intact resident with DM, heart disease, and kidney disease kept prescription nystatin ointment at bedside and used it as needed, but no SAM assessment was completed or documented. Staff and the DON confirmed the resident was never assessed for safe self-administration, no provider order or care plan update was obtained, and the discontinued medication remained in the room.
Failure to assess a resident for self-administration of nebulized medications. An LPN administered arformoterol and budesonide by nebulizer, then left the resident unattended during both treatments even though there was no order allowing self-administration. Record review showed prior self-administration assessments did not find the resident competent to self-administer medications, and the DON stated assessments were expected before residents were left unattended during medication administration.
Two residents had medications left in their rooms without the required self-administration assessment and provider order. One cognitively intact resident was using unlabeled fluticasone nasal spray kept on the bedside table, even though the self-administration assessment said she did not want to self-administer or keep meds at bedside. Another cognitively intact resident kept a 3/4 full bottle of Pepto Bismol on the nightstand for prior diarrhea episodes, but the MAR had no order and the assessment also said she did not want meds left at bedside. Staff and the DON confirmed meds from home should be labeled, ordered, and not left in rooms without proper assessment.
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.