A resident admitted with disc degeneration and back and leg pain had an order for oxycodone-acetaminophen PRN, but the medication was not given while it was unavailable from the pharmacy. Staff contacted the pharmacy for an ETA, but the RN did not use the automated med dispensing system or contact the provider for an alternate pain med order, and the resident’s family later removed the resident AMA due to concerns including the lack of the prescribed analgesic.
Medication administration records and narcotic tracking logs did not match for 3 residents receiving opioid pain meds. A resident with chronic pain had multiple hydrocodone removals that were not documented on the MAR, and some MAR entries showed doses given before the narcotic log showed the med was removed. Two other residents also had discrepancies between opioid removal logs and MAR documentation, and staff acknowledged the mismatches.
Pharmacy services failed to ensure two residents received ordered HIV antivirals as prescribed. One resident missed multiple doses of emtricitabine-tenofovir AF and also had a missed dose of azithromycin, while another resident missed multiple doses of bictegravir-emtricitab-tenofov. Staff said the medications were not available in the facility and were delayed because of insurance and pharmacy delivery issues, and the residents reported being told their HIV medications were not available.
A resident admitted from the hospital with diabetes and hypothyroidism missed several ordered meds, including insulin, thyroid meds, a muscle relaxer, and an antacid, because the meds were not available when needed. The MAR and facility investigation showed missed doses on the evening shift after admission, and an LPN later confirmed the meds had not yet arrived from the pharmacy while the resident’s blood sugar was elevated and required physician notification and extra insulin.
A resident who was not approved to self-administer meds was observed with a pill cup on the bedside tray after an NA moved it from the bedside table. An LPN later found the cup contained oxybutynin, baclofen, and oxycodone and asked the resident to take the meds before leaving the room; the LPN and DON stated nurses should witness residents taking medications before leaving the room.
Controlled medication counts were not accurately reconciled on the Central and South med carts. An LPN stated controlled meds had been administered earlier in the morning but were not signed out until later, and the narcotic ledgers did not match the actual counts for several residents’ antiseizure, narcotic pain, and liquid narcotic medications. The DON stated staff were expected to sign out narcotics at the time they were given.
Medication transcription errors affected two residents. One resident with COPD had a prednisone order transcribed at half the prescribed dose and received the incorrect dose for four days. Another resident’s MAR omitted atorvastatin and prednisolone acetate eye drops, causing four missed days of both medications. The RN/CNO stated two LNs were expected to double-check hospital discharge orders and admission orders, and acknowledged recent transcription errors had resulted in medication errors.
Missed Physician-Ordered Pain Medications: Two residents did not receive ordered oxycodone on time. One resident with metastatic cancer and a femur fracture had severe pain on admission and did not receive the narcotic until the next morning, while another resident with fibromyalgia missed multiple oxycodone doses because pharmacy access issues and a new script were needed. Staff said the facility had an emergency medication dispensing cabinet, but the ordered pain meds were still not obtained as expected.
Controlled substance records on a medication cart were incomplete and did not consistently show required witness signatures. Pregabalin for a resident was transferred between narcotic book pages without full transfer details, and oxycodone waste entries for another resident did not include a second nurse witness signature; one entry also did not show what happened to the remaining tablets.
Medication administration services failed for multiple residents when two nurses documented meds as given on the MAR even though the meds remained on the cart and were not administered. Residents with severe neurologic impairment, heart disease, diabetes, and HTN missed ordered meds including antihypertensives, anticoagulants, antidiabetics, and an anticonvulsant, and the DON confirmed the doses were not given.
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.