Failure to Administer Ordered Medications and Follow Prescriber Parameters Multiple residents had provider-ordered meds, treatments, or monitoring not carried out as documented in the MAR/TAR. An LPN and other nursing staff recorded missed doses or nonadministration even when meds were available in OTC stock or the Med Bank, including pain, thyroid, vitamin, seizure, COPD, and antibiotic therapies. One resident’s ER antibiotic order was not addressed in a timely manner, and another resident received a beta blocker despite BP being below the hold parameter. A PRN antihypertensive order was also reviewed in relation to BP readings.
An LPN left the west wing without giving report or completing the narcotic count, and no licensed nurse was present on the unit overnight. Residents reported missed bedtime meds, unanswered requests for pain relief, and waiting all night for medications, while MAR review showed no nurse signatures for several scheduled and PRN meds. One resident also reported a pain cream was not applied, and staff described the situation as unsafe because there was no nurse to take over the med cart.
A resident with persistent nausea, vomiting, dizziness, and declining BP did not have the ordered workup consistently completed or documented, including ultrasounds and lab testing, and the chart did not show refusal documentation, discussion of alternatives, or a GI referral despite ongoing symptoms. Nursing notes documented low BP, poor intake, and dizziness, and a later neuro check showed very low BP without physician notification before the resident was found on the floor, became unresponsive, and CPR was initiated.
Failure to Follow Insulin Hold Parameters: A resident with DM2 and multiple comorbidities had an insulin glargine order with a hold parameter for blood glucose less than 200 mg/dL, but nursing documentation showed insulin was given on several occasions when the resident’s blood glucose was below that threshold. The physician and NP continued to document the same hold parameter, yet the MAR later reflected a different instruction to call the provider only if blood sugar was less than 60 or greater than 400, and the DON stated nurses are expected to read and follow the full prescriber order.
Failure to follow hold parameters for Toprol XL: A resident with CHF, COPD, HTN, CAD, prior MI, and moderate cognitive impairment had an order for metoprolol to be held if HR was <60 or BP was <100/60. The MAR documented the medication as given even though the resident’s BP was 94/58, and the ADON agreed it was administered outside the ordered parameters.
An LPN failed to administer multiple ordered meds/treatments to a resident with stroke, DM, HTN, respiratory failure, dysphagia, and GERD during a delayed med pass when the unit was short staffed, and the MAR showed the ordered 9:00 a.m. meds were not given. Staff also failed to document descriptive wound assessments for another resident’s bilateral thigh gunshot wounds; notes and provider entries recorded the wounds and dressing changes, but did not describe wound size, appearance, drainage, odor, or surrounding skin as required by the facility’s wound care policy.
Failure to Administer Ordered Antibiotic Course: A resident with spina bifida, paraplegia, bladder dysfunction, diabetes, and moderate cognitive impairment did not receive a full ordered course of IM ertapenem for a UTI. The MAR showed missed doses and a refusal, the record lacked a note explaining one missed dose, and only 5 of 7 ordered doses were given despite the provider order for daily therapy.
Failure to Administer Ordered Gabapentin: Staff did not follow a provider order for Gabapentin for a resident with severe cognitive impairment, quadriplegia, ventilator dependence, and chronic pain syndrome. The MAR showed two missed doses, while nursing notes stated the medication was on hold until the prescription came in; however, the Omnicell inventory listed Gabapentin as available, and the DON stated staff should have pulled it from the emergency supply.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
A resident with a history of cerebrovascular disease, hemiplegia, dysphagia, and GERD had a physician order for a daily 81 mg chewable aspirin. Instead, an LPN crushed an 81 mg delayed-release (enteric-coated) aspirin tablet, mixed it with applesauce, and administered it, contrary to the specific order for a chewable form and despite facility policy and manufacturer guidance not to crush enteric-coated medications. The DON confirmed that this type of aspirin should not be crushed, and facility policy required following manufacturer "do not crush" recommendations.
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.