PEG feeding bottles for two residents were observed without the required date, time, and nurse initials. The ADON confirmed the bottles were not labeled and stated there was no way to know how long they had been running. One resident had severe cognitive impairment with diagnoses including CHF, stage 4 sacral pressure ulcer, osteomyelitis, severe malnutrition, and dysphagia; the other had hemiplegia and hemiparesis following cerebral infarction.
Unlabeled PEG Feeding Supplies: A resident receiving enteral nutrition via a PEG tube had a feeding bag, water flush bag, and syringes in the room that were not properly labeled or dated. An LPN confirmed the feeding bag lacked the required information, and the DON stated all tube feeding solutions and supplies should be labeled with the resident’s name, date, time, and rate; the facility also did not have a PEG-specific labeling policy.
PEG Tube Feeding Not Administered per Order: A resident with a PEG tube was observed self-administering a brown liquid through the tube with a syringe, but there were no MD orders permitting independent administration and no documentation of an assessment for safe self-administration. RN staff stated tube feeding or supplements must be given by staff and monitored, and the ADON and Administrator said the resident should not have been doing this independently. The resident had a hx of laryngeal cancer and a BIMS score of 10, indicating moderate cognitive impairment.
A resident with Alzheimer's disease and severely impaired decision-making skills had a tube feeding bag in use that was not labeled with the date, time, type of feeding, or the initials of the nurse who prepared or hung it. The DON confirmed the missing information and stated the night nurse was responsible for labeling the bag so it could be changed within 24 hours of use.
A resident with a feeding tube was observed with an enteral feeding bag hanging without a date or time label. The resident had an order for Two Cal at 40 ml/hr and a history of dysphagia following cerebral infarction. An LPN and the DON stated the bag should be labeled and dated to show when it was hung and to ensure it is used within 24 hours to prevent expiration, contamination, and bacterial growth.
PEG tube care was performed improperly for a resident with hemiplegia and dysphagia. An RN cleaned the PEG site with the same gauze in a circular motion multiple times instead of discarding and replacing the gauze with each wipe, contrary to infection control standards and the resident’s PEG care orders. The RN acknowledged the error, and the DON stated the repeated wiping could cause infection, skin irritation, and discomfort.
An LPN flushed a resident’s gastrostomy tube with water and administered medications without first verifying tube placement. The resident had anoxic brain injury and received feedings through a gastrostomy tube. The facility policy required tube placement to be checked before any fluids or medications were given, and the DON confirmed placement should be verified prior to flushes or medication administration.
Failure to follow peg site care orders for a resident with a PEG tube. An LPN cleaned the site with NS using the same Q-tip in a back-and-forth circular motion and applied a dressing without drying the site first, despite the physician order to clean with NS, pat dry, and apply a drain sponge. The resident had dysphagia and was cognitively intact.
A resident with a PEG tube did not receive appropriate care when an LPN withdrew gastric residual during a medication pass and discarded it instead of returning it to the resident, contrary to facility policy and standard nursing practice. The DON confirmed that this action could result in weight loss or electrolyte imbalance. The resident was cognitively intact and had medical conditions requiring enteral feeding.
Two residents receiving enteral feedings did not receive proper care: one had a PEG site with an old, soiled dressing and no physician orders or monitoring for over 20 days, resulting in purulent drainage and infection, while another had a feeding bag that was not properly labeled with required information. Staff confirmed these deficiencies through observation and record review.
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 July 29, 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.