A resident with type 2 DM and a BIMS score of 14 out of 15 was receiving multiple diabetes meds, including Jardiance, Metformin, Novolog insulin, and Toujeo insulin. The physician ordered a HgbA1c every 6 months, but the test was not completed and no results could be located in the record. The resident also reported missing bedtime snacks on some nights, including the night before she said her sugar was low that morning.
Unnecessary Psychotropic Use and Inadequate Monitoring: A resident with dementia and a history of alcohol abuse was given multiple CNS drugs and psychotropics, including Ativan, Depakote, Haldol, Risperdal Consta, and Seroquel, with dose increases and medication changes made without timely prescriber assessment or clear indication. Staff did not complete ordered side-effect monitoring, behavior documentation was inconsistent, and the resident later had falls, confusion, fatigue, weakness, and acute decline before transfer to the hospital.
A resident with dementia was maintained on prophylactic Nitrofurantoin for recurrent UTI history, but the record lacked documentation of the benefit or appropriateness of the antibiotic. The resident also received Bactrim DS for a UTI while already on the prophylactic antibiotic, and staff stated the family requested the prophylaxis, but no physician documentation supporting the rationale was available.
A resident receiving Eliquis for a pulmonary embolus had no care plan or documented monitoring for signs or symptoms of bleeding or other adverse effects. The MDS RN confirmed the resident was on an anticoagulant, verified there was no anticoagulation care plan in the EMR, and stated there was no monitoring in place. The Administrator also acknowledged the concern, and the facility’s medication management policy did not address monitoring for adverse consequences of medication therapy.
Unnecessary psychotropic medication use and missing clinical rationale: two residents were prescribed duplicate antidepressant therapy without documentation supporting the combined regimen, and one resident received olanzapine for MDD without an appropriate documented indication. Record review and staff interview showed no charted risk-versus-benefit rationale or supporting MH documentation for the psychotropic use.
A resident with heart failure, pulmonary hypertension, and acute respiratory failure with hypoxia had active orders for both Trelegy Ellipta and Advair Diskus, even though Trelegy was to be stopped when Advair started. The MAR showed both inhalers were given over several days, and the UM confirmed both inhalers were present in the med cart while an RN stated both were administered. The facility policy on Medication Orders did not address unnecessary medications.
Failure to monitor vancomycin trough levels for a resident receiving IV vancomycin. The physician ordered weekly trough monitoring and faxing results to Infectious Disease, but the ordered troughs were not completed as scheduled and no results were available. The resident had sepsis due to MRSA, DM2, CHF, epilepsy, moderate cognitive impairment, and was dependent on staff for ADLs and mobility. An RN documented that an outside hospital ICP requested trough levels and none were found, and the DON/Acting ICN confirmed the missed monitoring.
Failure to implement GDR for a resident on fluoxetine. A resident with depression, anxiety, and adjustment disorder was receiving Prozac for targeted behaviors including agitation, withdrawal, and verbal aggression. Psychiatry documented that dose reduction and GDR were being pursued, but the facility did not follow through when the recommendation was made, and the DON agreed the GDR should have occurred but was missed.
Failure to Document Non-Pharmacological Pain Interventions Before PRN Opioids: Two residents received repeated PRN oxycodone-acetaminophen doses for pain, but the MAR and EMR contained no documentation of pain location or any non-pharmacological interventions attempted and failed before administration. Both residents had care plans calling for non-pharmacological pain relief measures, and the DON stated that such interventions should be attempted and documented before PRN opioids are given.
A resident with MS, depression, anxiety, chronic pain, and other significant conditions was prescribed Adderall without a documented ADHD diagnosis or other clear support for continued use. Records showed agitation, marijuana use, and repeated concerns from the HCP, psychiatry, and IDT that the stimulant was not appropriate, while the resident refused gradual dose reduction or discontinuation. The neurologist note reviewed did not document support for ongoing Adderall use, and the NP reported the medication appeared to contribute to irritability and behavioral outbursts.
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