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.
Inadequate monitoring of lactulose therapy: A resident ordered lactulose via PEG for elevated ammonia levels did not have a recent ammonia level documented, and the medication was not available during a med pass observation. Record review showed the last ammonia lab was months earlier, while the MAR continued to document lactulose administration. The resident also had senna documented as given and daily bowel movements recorded, with PRN PEG laxative ordered but not administered.
Failure to Monitor Anticoagulation Therapy: A resident receiving apixaban for atrial fibrillation had no documented monitoring for bleeding or other anticoagulation side effects in the EMR, and no care plan related to anticoagulant therapy. The DON confirmed the resident was on an anticoagulant and stated the monitoring task was not reordered after readmission.
Failure to Monitor Vital Signs Before Administering BP-Dependent Medications: Two residents received BP-dependent medications without required vital sign checks or with documentation that did not match the physician orders. One resident with heart disease and HF received Midodrine despite missing pre-dose BP checks and one dose given outside ordered parameters; another resident with HTN had Lasix administered or held based on prior readings or incorrect interpretation of the hold parameter. The DON confirmed the vital signs were not obtained before each ordered administration.
The facility failed to keep residents’ drug regimens free from unnecessary drugs when an antipsychotic was started for a resident with dementia and hospice status without documented non-pharmacological interventions or use of ordered PRN anti-anxiety medication first. It also failed to discontinue duplicate inhaled therapy after a pharmacist recommendation and physician order, and staff administered PRN pain meds to two residents without documenting non-pharmacological interventions before use.
A resident with dementia and severe cognitive impairment was given psychoactive medication for wandering, exit seeking, and agitation without documented rationale, target behaviors, or treatment goals. The record did not show that non-pharmacological interventions were tried before Lorazepam was started, and the RP was not informed of the medication’s indications, risks, benefits, or goals until after initiation. Care plans were not updated to reflect the behavior management approach or medication use, and facility interviews confirmed the missing documentation.
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