A resident with major depressive disorder had a pharmacist MRR note stating Trazodone could increase drowsiness and falls, with recent falls noted, and the physician response documented agreement to discontinue. However, the MAR continued to show daily administration of Trazodone at bedtime, and the DON and physician both stated provider orders were expected to be entered and followed.
A resident’s midodrine was administered multiple times despite MAR-documented BPs above the prescriber’s hold parameter of SBP > 120. The RN stated a check mark means the med was given and was unsure why the resident’s midodrine was marked that way, while the DON confirmed the med should not have been administered when BP was outside parameters and that the MAR check mark indicates administration.
A resident with dementia had orders for Quetiapine for hallucinations and Duloxetine for depression, but the MAR showed behavior monitoring only for the antipsychotic and not for the antidepressant. Progress notes also lacked documentation of mood or behavior changes related to depression or Duloxetine. An LPN and an RN stated that behavior and mood monitoring was expected for these psychotropic meds and should be documented on the MAR or in progress notes.
A resident on warfarin for a mechanical heart valve had critically elevated PT/INR values documented, yet nursing staff continued to administer warfarin, including during a period when the drug was ordered to be held. The MAR shows doses given on days when INRs were elevated, with no evidence that the physician was notified before administration. After a critically high INR, the provider ordered vitamin K and daily PT/INR labs for two days, but the ordered labs were not drawn as scheduled, and the next INR was not obtained until after the resident became nonresponsive and stopped eating. The DON later confirmed that the labs were missed and that there was no documentation of timely physician contact regarding the elevated INRs.
Failure to monitor psychotropic medication side effects: A resident with ESRD, DM2 with diabetic nephropathy, dementia, anxiety, and major depressive disorder was prescribed pregabalin and fluoxetine, with orders and care plan interventions to monitor for multiple psychoactive side effects. Psychiatry also recommended side-effect monitoring, but the MAR showed the resident was not monitored as ordered, and an LPN and the DON were unable to locate the monitoring order in the MAR system.
A resident’s pharmacy recommendations were not reviewed or signed by the attending physician or medical director for both PRN hydrocodone-acetaminophen and insulin glargine. The pharmacist said the pain medication frequency should have been changed, while the AP said he did not remember discussing the recommendations and expected them to be placed in his folder at each nursing station. The DON said he signs pharmacy recommendations but does not verify whether the AP approved or denied them.
A facility failed to monitor and document behaviors and side effects for two residents receiving psychotropic medications. One resident with cognitive impairment and diagnoses including anxiety, depression, and psychotic disorder was observed repeatedly calling out, trying to get out of a Geri chair, and appearing restless and agitated, yet the MAR/TAR contained no behavior or side-effect documentation. Another resident with dementia, depression, anxiety, and suicidal ideations had an order for every-shift psychotropic side-effect monitoring, but progress notes did not document side effects or physician notification.
A facility failed to ensure medications were administered only within ordered parameters for three residents. One resident received Cozaar when HR was below the hold limit and there was no provider notification documented. Another resident had Amlodipine and Metoprolol documented as given when BP or HR were below ordered parameters, and staff said one entry was a documentation error. A third resident’s scheduled insulin was documented as given when blood sugar values were below the hold parameter, with staff describing the entries as missed documentation.
Unnecessary Medication Administration Outside Ordered Parameters: Two residents received medications outside ordered parameters. One resident was given metoprolol despite BP readings below or near the hold limits, and an LPN stated it was administered in error. Another resident received topical diclofenac as ordered on the MAR until the order was discontinued, with an LPN stating she applied the gel but could not recall the amount. The DON stated staff were expected to clarify unclear medication orders and follow physician parameters, and the MD said he reviewed the residents and found no adverse events.
Surveyors found that nurses failed to follow physician-ordered vital sign parameters for antihypertensive medications for two residents. One resident with multiple chronic conditions, including essential hypertension and mild cognitive impairment, received metoprolol doses despite heart rates below the ordered hold threshold. Another resident received hydralazine even when systolic blood pressures were outside the specified parameters. Nursing staff acknowledged administering these medications outside the prescribed limits, and the DON confirmed that facility policy requires medications to be given in accordance with physician orders and associated vital sign checks.
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.