Failure to Check BP Before Metoprolol Administration: A resident with HTN and CHF received metoprolol despite an order to hold the medication if systolic BP was below 100. The nurse documented the dose as given without confirming a BP reading beforehand, and the resident’s BP was later recorded as 90/52. The NP confirmed the order required BP to be checked before administration, and the DON described the missed check as an oversight.
Expired Vitamin B12 was administered to a resident after an MA gave a daily dose from a medication cart bottle that had an expiration date of 1/2026 and still contained 92 pills. During the med storage observation, the MA stated she had already given the expired dose that morning and admitted she did not check the expiration date before administration. The MAR confirmed the resident received the Vitamin B12, and the DON and Administrator stated their expectation was that residents receive non-expired medications.
A medication aide gave one resident his scheduled meds and then, after returning to the cart, administered another resident's meds to the same resident because identity was not properly verified. The affected resident had Alzheimer's disease, severe cognitive impairment, DM, HTN, and sinus bradycardia, and the error involved meds including Eliquis, memantine, and omeprazole. The error was later reported to the nurse, and the resident was found to be bradycardic and hypotensive, with hospital records showing progression to complete heart block.
Failure to Provide Ordered Moisture-Associated Skin Treatment: A resident with moisture associated skin damage and urinary incontinence was ordered daily interdry under the abdominal folds, but staff documented the treatment as completed when it was not actually applied. The resident reported the supply had run out and a dry bath towel was being used instead; observations confirmed a towel in the folds, later saturated with urine. The DON, treatment nurse, and MD all stated the treatment should not have been signed off if it was not performed, and the towel was not an acceptable long-term substitute.
A resident with DM received insulin lispro outside the ordered BG parameters on multiple occasions. Staff gave half doses even when BG values were above the threshold for dose reduction, and an RN confirmed several of the discrepancies. The Medical Director and DON stated staff were expected to follow the physician’s orders as written.
Wrong Resident Transported to Scheduled Appointment: A resident with HF and impaired mobility was prepared for an ortho appt, but a transport driver picked up the resident’s roommate instead. The wrong resident was taken to the appt, identified there as not being the scheduled patient, and returned to the facility while the intended resident never arrived.
Wrong Resident Received Scheduled Medications: A medication aide gave one resident another resident’s scheduled meds, including doxepin, lamotrigine, folic acid, and acetaminophen, after the aide entered a room with only one name on the door, the curtain blocked the second bed, and the room change had not been updated in the computer system. The aide called out the intended resident’s name, got a response from the resident in bed A, and administered the meds before realizing the error. The resident who received the meds was monitored, remained sleepy but easily aroused, and later went to the ER; labs and EKG were normal, and the NP later noted the resident was back to baseline.
An LPN borrowed another resident’s Potassium Chloride ER tablets when a resident’s ordered potassium was unavailable and gave the resident two 10 mEq tablets instead of the prescribed 20 mEq dose. The resident, who was cognitively intact, said the nurse handed him two pills and left before he took them, and he saved one because he did not understand why he received two yellow tablets. The DON stated staff are not allowed to borrow medications from other residents and must observe residents taking their meds before leaving the room.
A medication aide left after only a few hours, and two nurses stated they did not give medications to residents on two halls for several hours afterward. As a result, multiple residents missed scheduled doses of Parkinson’s meds, antihypertensive therapy, buspirone, depakote, acetaminophen, and glaucoma eye drops that were ordered by the MD.
Failure to Implement Abdominal Wound Care Orders: A resident admitted after abdominal surgery with DM had wound care orders in the hospital discharge summary and later from the Wound Care NP, but the orders were not entered into the TAR right away and wound care was not documented for several days. The resident reported that after soiling the dressings, a nurse refused to change them, and she cleaned the incisions herself and left them open to air before wound care was finally started.
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.