A resident with CHF, CKD, and diabetes had a Bumex dose increased for fluid overload, but an RN discontinued the new order without a matching physician order and the resident missed doses for two days. The resident then developed SOB, had low O2 saturation, was sent to the ED, received IV Bumex, and was hospitalized after imaging showed pulmonary edema and bilateral pleural effusions.
A resident with epilepsy, hallucinations, and parkinsonism received Haloperidol nightly for months even though no valid physician order was found in the chart. The med was entered into the electronic system as if it were ordered for the resident, transmitted to the pharmacy, and administered by staff despite the lack of a corresponding provider order. Records and interviews showed the order may have been intended for another resident, hospice records did not match the facility MAR, and the drug was later discontinued after seizure activity.
Significant Lactulose Medication Error: A resident with hepatic encephalopathy, cirrhosis, and convulsions received an incorrectly transcribed lactulose order in the MAR that listed 10 g/15 mL instead of the ordered 30 g/45 mL. The resident also missed initial doses because lactulose was unavailable, then received multiple doses at the lower amount after an LPN relied on the MAR despite the bottle label mismatch. The resident later developed seizure-like activity and was hospitalized with severe hyperammonemia and new onset seizures.
A resident with dementia and Alzheimer's disease ingested another resident's crushed medications after an RN prepared the medications in a glass, placed it in front of the intended resident, and walked away, leaving it unattended. The cognitively impaired resident took the glass, drank the contents, and became lethargic, with her pulse dropping from her usual rate to the 30s–40s bpm. She was sent to the ED, where it was determined she had ingested multiple medications, including metoprolol, and was diagnosed with a medication overdose and bradycardia requiring IV fluids and glucagon.
A resident with diabetes and multiple comorbidities experienced significant medication errors when rapid-acting insulin aspart, ordered as a sliding scale to be given with meals, was administered mid-afternoon without a meal and then inaccurately documented on the eMAR as noon and evening doses. Later that day, the resident was found incoherent, cold, and clammy with critically low blood glucose and required transfer to the hospital. Surveyors also observed that the same resident’s scheduled morning medications, including insulin glargine, cardiac, anticoagulant, pain, and respiratory drugs, were administered nearly three hours late, and the resident reported that medications were often more than an hour late, affecting pain control and breathing. The NP and pharmacist confirmed that rapid-acting insulin should not be given between meals and that key medications should be administered on a consistent schedule, while the DON and Administrator acknowledged these were medication errors.
A resident with hypomagnesemia and multiple serious diagnoses had an order for oral magnesium 250 mg daily that was not administered for five consecutive days, with MAR entries coded as unavailable and nursing notes stating the medication was on order or awaiting pharmacy delivery. Magnesium was an OTC item stocked in the facility, but the correct strength was not requested via house stock procedures, and the provider was not notified of the missed doses. During this time, labs showed persistently low magnesium, and documentation noted fatigue, lethargy, nausea, poor intake, and leg pain. An NP later documented that the resident’s magnesium supplement had not been started due to tablet strength issues, the pharmacy reported no request for the ordered dose, and the DON learned of the omissions only on later chart review. The Pharm-D characterized the five missed doses, in the context of the resident’s symptoms and lab values, as a significant medication error.
A resident with CHF and anxiety did not receive a physician-ordered lorazepam for several days because the facility and pharmacy had conflicting dose orders, and the issue was not resolved over the weekend. Progress notes showed the medication was unavailable, the nurse manager later identified a 0.25 mg vs 0.5 mg discrepancy, and family members questioned why the order had not been handled sooner. The DON and administrator said they were unaware of the problem, and the pharmacy reported the original order was not a valid controlled-substance prescription because it lacked required elements.
A resident with chronic pain and muscle spasms did not receive scheduled baclofen at the ordered 7:30 a.m. time, and morning meds were repeatedly given late, sometimes after 11:00 a.m. The resident and family reported the delays caused pain, and staff confirmed the meds were expected to be given at the ordered time or within the usual medication window.
Surveyors identified significant medication errors involving two residents. One resident with cardiac and neurologic conditions received conflicting and duplicate metoprolol orders that were not clarified, resulting in administration of both metoprolol succinate and metoprolol tartrate at overlapping doses and frequencies. Facility staff failed to reconcile discrepancies between hospital, cardiology, and pharmacy orders, did not complete required verification checks for telephone orders, and documented ongoing administration of incorrect dosing on the MAR while the resident reported dizziness and feeling worse. A second post-surgical resident with cervical spine fusion did not receive ordered PRN oxycodone and acetaminophen in a timely manner; pain medications were not available on admission, the resident experienced severe pain before receiving relief, and documentation showed both a delay in initial dosing and administration of oxycodone at intervals shorter than the every-4-hours PRN order. Interviews confirmed breakdowns in following established processes for obtaining and administering medications from the pharmacy and the facility’s medication bank.
A resident with complex cardiac and renal conditions was given another resident’s full set of morning medications when an agency TMA entered the wrong room and failed to verify identity or follow the rights of medication administration, leading to unresponsiveness, hypotension, and acute kidney injury requiring hospitalization. During observation of other medication passes, an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and another resident with heart failure, Parkinson’s disease, dementia, and hospice services received an extra scheduled dose of lorazepam when a TMA assumed there was a PRN order and did not verify the MAR. Multiple TMAs and an RN demonstrated incomplete understanding of the rights of medication administration, and medication pass audits and competencies had been performed by an unlicensed administrator without formal medication training and by LPNs, despite facility policy requiring verification of resident identity and triple-checking the right resident, medication, dose, time, and route.
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