The facility’s medication error rate was 6.9%, with 2 errors found in 4 observed med passes. One nurse gave an insulin dose without priming the pen first, and another did not ensure a resident rinsed and spit after using a steroid-containing inhaler. The residents involved had DM and COPD, respectively, and both were moderately cognitively impaired.
Medication error rate exceeded 5% when an LPN crushed and administered two extended-release medications to a resident with heart failure, despite one order stating not to crush and the other being an ER tablet. During a med pass observation, the nurse placed potassium chloride ER and metoprolol succinate ER in the same cup, crushed both, and gave them to the resident; the DON stated the nurse should have compared the package to the orders and recognized the no-crush instructions.
Medication error rate exceeded the 5% threshold when an RN administered two insulin doses to a resident with DM without priming the Lantus and NovoLog pens before each injection. Surveyors observed the RN give the ordered subcutaneous doses without completing the manufacturer-required safety test, and the RN stated she believed priming was only needed before first use. The DON and consultant pharmacist confirmed the pens should be primed before each dose.
A medication pass observation found an LPN gave a resident a chewable aspirin tablet instead of the ordered delayed-release aspirin and did not administer the ordered estrogen tablet. The DON stated medications were expected to be given exactly as ordered, and the facility’s medication error rate was 6.67%, above the allowed 5% threshold.
Medication Error Rate Exceeded 5% Due to Improper Crushing of Extended-Release Medications: A resident with diabetes, vascular dementia, epilepsy, and depression received multiple medication administration errors when an LPN crushed extended-release carbidopa-levodopa and metoprolol succinate and opened duloxetine capsules for applesauce administration based on shift report and a printed note. The LPN later stated she should have recognized the extended-release medications should not have been crushed, and the DON stated the nurse should have checked the chart and MAR instead of relying on verbal report and the shift-change paper.
Medication Error Rate Exceeded Allowed Threshold: A resident with anemia, muscle weakness, and depression received medication pass errors when an MA omitted an ordered B Complex supplement and gave only one tablet of Sertraline 25 mg instead of the ordered three tablets plus a 100 mg tablet. The MA stated she missed the B Complex on the MAR and did not notice the full Sertraline dose; the DON stated the usual process was to compare the medication cards to the MAR before administration, and the PA stated medications should be given as ordered.
Medication Error Rate Exceeded 5 Percent: Surveyors found an 11.5% med error rate during an observation of five residents. An RN gave a resident with CHF only half of the ordered Torsemide dose and documented the full dose, and gave another resident Vitamin C without a current order plus only half of the ordered Vitamin D dose. The RN acknowledged the errors, and the consultant pharmacist stated staff must follow the MAR and physician orders before administering meds.
Medication Administration Errors Exceeded Allowed Rate: Surveyors found an 11.5% med error rate after observing a medication aide administer meds to a resident with heart failure. The aide did not follow the ordered timing for metolazone and bumetanide and did not instruct the resident on the correct dose of fluticasone nasal spray, resulting in multiple med administration errors.
Medication Error Rate Exceeded Threshold: The facility had 3 medication errors out of 39 opportunities, resulting in a 7.69% error rate. One nurse failed to administer ordered cholecalciferol and fenofibrate to a resident with vitamin D deficiency and hyperlipidemia because the stock dose did not match the order and one medication was unavailable. Another nurse administered a fluticasone propion-salmeterol inhaler to a resident with COPD but did not prompt the resident to rinse and spit as directed by the manufacturer.
Surveyors identified a medication error rate above 5% when a nurse, unable to locate a prescribed polysaccharide iron complex capsule for a resident with iron deficiency and other conditions, substituted and administered an acidophilus probiotic tablet that had no corresponding physician order. The nurse stated she believed the two could be interchanged because they were both probiotics. Subsequent interviews with nursing leadership and the NP confirmed that the two medications are different, should not be substituted by staff, and that the provider should have been notified when the ordered medication was unavailable, resulting in the resident not receiving the prescribed iron supplement.
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.