A CP failed to identify and document medication route discrepancies during the monthly DRR for a resident who was NPO and receiving TF. The resident had dysphagia, a gastrostomy, and a cerebral infarction, yet the MAR/POs included oral orders for Mylanta and Milk of Magnesia. The DON and UM confirmed the mismatch, and the CP report did not note the irregularity.
A facility failed to act on CP medication regimen review recommendations for three residents. Issues included unaddressed PRN psychotropic and pain-med orders, lack of stop dates and rationale for PRN insomnia meds, failure to clarify pain scales for PRN analgesics, and an acetaminophen liquid dose that was difficult to measure. Nursing staff acknowledged some of the orders were confusing, and one resident received PRN tramadol even when the documented pain score was 0.
Failure to act on CP medication review recommendations. A resident with DM2, severe sepsis, and intact cognition had orders for Lispro insulin, ropinirole, Flomax, and Protonix. The CP identified administration concerns for each medication, including timing and crushing/opening restrictions, but the EMR showed no evidence the facility followed up on the recommendations or documented that they were addressed.
A resident with type 2 DM, gait and mobility abnormalities, and severe cognitive impairment did not receive a documented monthly medication regimen review from the pharmacy consultant for one month. The PC binder showed only the initial admission EPIC review, and the DON stated the resident was in the hospital when the PC visited that unit, leaving no documented February MRR.
The facility failed to timely act on pharmacy consultant recommendations for two residents. One resident had incomplete PRN bowel medication orders and was receiving cetirizine 10 mg daily despite a lower recommended dose for older adults, while staff could not explain the MRR follow-up process and the DON was unsure of the required timing. Another resident with hypothyroidism had a levothyroxine administration time that remained inconsistent with the consultant’s recommendation for months, and the DON acknowledged the recommendation should have been addressed sooner.
A resident with severe cognitive impairment and G-tube feeding had CP recommendations left unsigned and not documented as followed up. The CP had recommended clarifying a Flomax order because the capsule should be swallowed whole and adjusting Lidoderm patch timing to 9 AM to 9 PM, but the MAR showed different patch times and the record initially showed no follow-up by the DON or nursing staff.
A resident with Parkinson’s disease and an unhealed sacral pressure ulcer had wound orders for Dakin’s-soaked gauze, but the strength was not documented on the new order and was later shown on the TAR as 0.5% without evidence that the MD was contacted to clarify it. The CP stated he reviewed the TAR only every 6 to 12 months, and the monthly MRR for the resident’s chart did not identify any medication irregularity or make any recommendations.
Consultant Pharmacist Failed to Identify Medication Timing Irregularities: A resident’s med regimen included Lokelma for hyperkalemia and Questran for hyperlipidemia, both of which have administration timing requirements relative to other meds. During med pass, an LPN prepared both meds for the resident, but the CP’s MRR did not identify the irregularity or recommend changes to the administration times. The CP later acknowledged she had access to the eMR and did not identify the issue.
A resident with dementia did not have a monthly CP medication regimen review documented in the chart, and another resident with severe cognitive impairment received duplicate docusate orders during med pass. The CP had recommended changing one docusate form and later flagged that Colace appeared twice on the eMAR, but the facility had no documented response to the recommendation.
Failure to act on Consultant Pharmacist MRR recommendations: A resident with vascular dementia and severe cognitive impairment remained on duplicate constipation medications, Colace and Senna-S, even after the provider agreed with two pharmacist recommendations to evaluate and discontinue one of the orders if appropriate. The MAR still showed both meds being administered daily, and the physician orders had not been updated to reflect the agreed recommendations.
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