An LPN failed to assess and document a resident’s headache pain before giving PRN oxycodone and also failed to document the medication administration on the MAR. The resident was alert and oriented, had WNL vital signs, and the LPN completed a negative stroke assessment, but did not obtain a pain score or record the PRN dose as required by the MAR and facility policy.
An LPN administered an incorrect dose of Norco to a resident by giving three tablets instead of the ordered two, and a separate RN failed to complete required 72-hour post-incident EMR documentation after a resident had a choking/aspiration event while on a mechanical soft diet. The resident returned to baseline after the event, but the record lacked progress notes, assessments, and vital sign documentation for the monitoring period.
A resident with a left foot wound and infected diabetic ulcer had physician antibiotic orders entered incorrectly into the EMR by an RN. The IM antibiotic was entered with the wrong start date, causing the resident to miss the first dose, and the resident later required hospitalization and amputation of the left foot’s 5th toe.
A resident with a severe sacral Kennedy ulcer, osteomyelitis, and a wound vac did not receive the ordered dressing change when due. An RN said she only changed the canister, was not comfortable doing the dressing change alone, and did not call for help, then passed it to the next shift. When the dressing was finally changed, the wound was odorous with abnormal drainage and had worsened, and the resident was sent to the ER with fever and low BP; the ER noted erosion to bone and diagnosed cellulitis.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
A resident had seven blood glucose readings over 400 mg/dL, but six of the elevated results were not reported to the physician. The resident’s BG checks and sliding scale insulin orders did not include parameters for notifying the MD, and staff interviews showed differing expectations about using order parameters versus protocol/standing orders. The facility’s protocol orders stated the MD should be contacted for BG less than 60 mg/dL or greater than 400 mg/dL unless otherwise specified.
A resident with COPD and a history of thrush received budesonide nebulizer treatments, but staff did not consistently rinse the nebulizer mask or instruct him to rinse his mouth after treatments. The resident reported that nurses or CMAs often left the room during treatments and that he was not told to rinse afterward, while the EMR showed budesonide orders that specifically instructed mouth rinsing to help prevent oral thrush. Staff interviews and the manufacturer's instructions showed the nebulizer chamber and face mask were to be cleaned after each use, but practice at the facility did not consistently follow those directions.
Staff failed to follow professional standards when a physician verbally instructed the DON to have nurses borrow a controlled medication (Lorazepam 0.5 mg) from one resident and administer it to another resident experiencing anxiety after other comfort measures failed. Because the ordered medication was not available on site, the pharmacy was closed, and the family declined ER transfer, an LPN removed a Lorazepam tablet from the first resident’s medication card and gave it to the second resident. This action bypassed facility policies requiring proper ordering, accountability, and use of controlled drugs only for the resident for whom they were prescribed, and the administrator, DON, and consultant pharmacist later acknowledged that borrowing medications between residents is not acceptable practice.
A CMA administered the wrong dose of potassium chloride ER to a resident after verifying the MAR and blister pack label matched. The CMA gave one tablet even though the physician’s order required 2 tablets by mouth daily, and the DON confirmed the dose was incorrect. Facility competency guidance stated staff were expected to follow the rights of medication administration, including the right dose.
A resident with DM and diabetic CKD had repeated low blood sugars, but staff did not notify the physician when readings fell below the ordered threshold, despite orders to report values under 70 mg/dL. Another resident with acute respiratory failure with hypoxia had an order for O2 at 2 L via nasal cannula to keep sats above 90%, but SpO2 monitoring was infrequent and not documented as ordered. Staff and the DON confirmed the expected monitoring and notification practices were not being followed.
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 August 26, 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.