Controlled Substance Log Signed Before Administration: An LPN signed the narcotic log in advance for scheduled controlled meds for five residents, including opioid and antianxiety doses that were not yet due. The facility policy required accountability and security for controlled substances, but it did not describe the documentation process for administration on the log. The RN unit manager stated the log should be signed only after the med was given, not for the whole shift at the start.
Failure to Administer Ordered Medications and Treatments: Two residents did not receive ordered meds/treatments as scheduled. One resident with bipolar disorder missed quetiapine doses when the pharmacy had not delivered the medication, and the record did not show pharmacy follow-up, MD notification, or alternate orders. Another resident with chronic pain missed lidocaine patch applications when the resident was already out of bed, with no later attempt documented and no MD notification or alternate instructions noted.
Surveyors found that the facility failed to maintain accurate and secure controlled substance management on one unit. An LPN and another nurse did not complete required two‑nurse narcotic counts before exchanging keys, and several controlled drug records did not match the actual quantities on hand. For multiple residents receiving Vimpat, gabapentin, hydrocodone‑acetaminophen, and PRN lorazepam, doses were signed out on controlled substance logs with incorrect balances, one PRN lorazepam dose was signed out but not documented as given on the MAR, and a poured dose of liquid Vimpat was left in a cup inside the narcotic compartment instead of being administered or wasted. Staff interviews confirmed that counts were sometimes estimated, done by a single nurse, or pre‑signed, contrary to facility policy requiring real‑time documentation, two‑nurse reconciliation, and immediate wasting of unused controlled doses.
A resident with multiple chronic conditions and a documented allergy to Vancomycin received IV Vancomycin after a new order was written and processed. The allergy had been added to the care plan and physician orders, and the pharmacy profile reflected the allergy, but the pharmacy’s dispensing system was not updated to flag it, and the RN who administered the dose failed to check the allergy information. The resident subsequently developed increased work of breathing and facial and lip swelling while receiving the infusion, and a medication error report cited failure to check allergies as the cause.
Two residents with cardiac, thyroid, cognitive, and anxiety-related conditions did not receive multiple ordered medications, including alprazolam, diltiazem, methimazole, nadolol, hydralazine, and lisinopril, because the drugs were out of stock, pending from pharmacy, or awaiting delivery. Nursing staff did not consistently reorder medications in advance, did not always use or verify the emergency medication supply, and did not reliably notify supervisors or medical providers when medications were unavailable, despite facility policies requiring these actions. Documentation showed missed doses over several days, an elevated BP reading after a missed cardiac medication, and gaps in provider notification and progress notes, while staff interviews described frequent problems with the new pharmacy’s refill and delivery processes and inconsistent monitoring of remaining medication supplies.
Insulin Pen Not Primed Before Administration: An LPN administered aspart insulin to a resident with diabetes using a pen injector without priming the pen first. The resident had moderately impaired cognition and received daily insulin injections. The LPN stated priming was not needed, while the RN Unit Manager stated the pen should be primed with a waste dose before use to ensure the correct dose is delivered.
Incomplete Controlled Substance Count Documentation: The facility failed to keep controlled substance records in order and did not consistently obtain both oncoming and off-going nurse signatures on narcotic count books across multiple units. Observation and record review showed repeated missing signatures on shift count forms, and staff interviews confirmed they knew the count was supposed to be completed and signed by two nurses together at each shift change.
Controlled drug counts and narcotic documentation were not consistently completed. Narcotic count sheets on multiple med carts had numerous missing on-coming and off-going nurse signatures at shift change, and one LPN did not document a resident’s lorazepam administration at the time it was given. Facility policy required two nurses to count controlled meds at each shift change and the administering nurse to initial the eMAR after giving each medication.
The facility failed to maintain an effective system to reconcile and verify methadone doses supplied by external opioid treatment programs, resulting in multiple residents with opioid use disorder receiving methadone under conditions where physician orders did not match the dosages on clinic-labeled bottles. Despite existing policies for controlled substances and medication administration, there was no specific policy, procedure, or formal agreement governing methadone from outside clinics, and staff did not receive or use clinic documentation to confirm current dosages. Nurses reported relying mainly on resident names on bottles and did not routinely compare bottle dosages to physician orders, while physicians and the consultant pharmacist described processes in which methadone orders were entered or signed based on bottle labels without independent verification. These systemic gaps led to repeated discrepancies between ordered and labeled methadone doses for numerous residents.
A resident with opioid dependency and other medical conditions was readmitted from the hospital with an existing order for daily methadone, but the facility did not have the methadone on hand and the scheduled dose was not administered. Nursing documentation showed the medication was unavailable, and the resident became upset and verbally agitated when it was not provided. Staff interviews indicated the facility had not received discharge paperwork or prior notice of the resident’s return, the methadone clinic was closed on weekends, and coordination with the hospital to ensure methadone availability before discharge did not occur.
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.