The Consultant Pharmacist failed to identify and report an irregularity during monthly MRR for a resident receiving PRN trazodone, an antidepressant used for agitation. The resident had Alzheimer’s disease, dementia with mood disturbance, and severe cognitive impairment, and the chart did not show ongoing prescriber re-evaluation or a stop date for the PRN psychotropic order. Despite repeated MAR administrations and monthly MRRs showing no irregularities or recommendations, staff interviews confirmed the PRN psychotropic should have been re-evaluated and documented.
The facility failed to ensure monthly MRRs were communicated to the prescriber and addressed for two residents. One resident with dementia, Parkinson’s disease, and anxiety had pharmacist recommendations about a Midazolam allergy clarification and lab monitoring for Risperdal that were left blank and unsigned, with no chart evidence that the MD/NP reviewed them. Another resident with anxiety, dementia, and depression had PRN Trazodone orders that were signed on the MRRs, but the record did not show re-evaluation, a progress note with medical justification, or a specified duration for continued use.
Failure to maintain monthly pharmacy MRRs and document physician review of consultant recommendations for multiple residents. A resident with DM, chronic pain, and depression continued receiving several meds despite pharmacist suggestions to deprescribe, adjust basal insulin, and reassess pain control; another resident on aspirin and Eliquis had a prompt clinical recommendation with no documented prescriber response; and a third resident with dementia, allergies, and chronic pain had missing MRRs and no documented action on recommendations for acetaminophen, Seroquel, and loratadine.
A resident with glaucoma, dementia, and bipolar disorder had orders for multiple eye drops, and the Consultant Pharmacist repeatedly recommended separating the drops by at least 5 minutes during administration. The record did not show that the provider reviewed or responded to the recommendation in a timely manner, and the DON stated that a two-month delay in implementing pharmacist recommendations would be considered a delay in care.
Two residents had pharmacy recommendations from MRRs that were not reviewed or addressed in a timely manner. One resident’s Flonase recommendation to change to PRN was not signed or dated by the physician, and another resident with dementia and PRN quetiapine had no documented AIMS assessment within the required timeframe despite the pharmacist’s recommendation and the care plan’s monitoring focus.
A resident with COPD, depression, and opioid dependence had monthly MRR recommendations that were not communicated and addressed in a timely manner. The consultant pharmacist repeatedly flagged two PRN albuterol orders, Paxil dosing above the recommended daily dose, and the need for a PRN Narcan order, but the related pharmacy reports were missing from the chart and the provider response was incomplete.
MRR recommendations were not timely addressed for a resident receiving weekly Vitamin D. The consultant pharmacist recommended checking a Vitamin D level to see if the dose could be reduced, but nursing did not transcribe or complete the lab order when the physician signed it, and the recommendation had to be reissued. The DON and nursing staff stated they did not have a reliable process to ensure pharmacy recommendations were followed through.
Failure to address consultant pharmacist recommendations for PRN psychotropic orders. Two residents had active PRN Trazodone orders without documented stop or evaluation dates, and pharmacy reviews repeatedly noted the missing stop dates. One resident had depression and moderate cognitive impairment, and the other had Alzheimer's disease, depression, and severe cognitive impairment. The record did not show that the later recommendations were reviewed by the physician or that the orders were updated.
Pharmacy MRR recommendations were not reviewed or documented timely for two residents. One resident with hyperlipidemia had a pharmacist recommendation about continuing a statin and possibly adding CoQ10, but the chart lacked the pharmacist’s recommendation and the physician response. Another resident with anxiety and depression had repeated MRR recommendations for updated consents for Cymbalta, Trazodone, and Remeron, yet the chart contained outdated or incomplete consents and the DON could not locate additional signed consents.
Failure to address a pharmacy recommendation for a resident with anxiety and major depressive disorder. The consultant pharmacist noted a PRN alprazolam order without a stop date and recommended discontinuing, scheduling, or adding a stop date if the medication remained PRN, but the medical record did not show physician response or documentation. The DON stated pharmacy recommendations should be addressed by the physician and documented in the record.
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