A resident with osteomyelitis, a clavicle fracture, and a history of addiction received changing orders for Suboxone and oxycodone, including concurrent use for pain and OUD. The DON stated she questioned why Suboxone and oxycodone were being given together because Suboxone can block oxycodone’s effects, and the MD stated a 10 mg oxycodone dose would provide only a placebo effect for a resident taking Suboxone.
Unnecessary medications were ordered without appropriate diagnosis-based indications. Two residents had medications ordered for uses that did not match their current diagnoses: one resident received mirtazapine, trazodone, and omeprazole for indications not supported by the record, and another resident received mirtazapine, quetiapine, and melatonin for sleep or behavior management without corresponding diagnoses. The ADON confirmed the indications were not appropriate for the documented conditions.
A resident with DM2, anticoagulant use, and edema was observed with visible redness and swelling in both lower legs while socializing in the dining room and stated he has daily swelling and takes medication for it. His physician orders did not include edema monitoring, and a pharmacy MRR recommended monitoring for increased edema and notifying the physician if present. The DON confirmed the care plan was not updated to reflect edema management while on a diuretic.
Surveyors found that multiple residents were receiving medications without corresponding documented diagnoses or appropriate monitoring. Several residents were prescribed drugs such as ropinirole, allopurinol, Keppra, gabapentin, Suboxone, methocarbamol, benztropine, melatonin, risperidone, sertraline, and olanzapine for indications like RLS, gout, seizures, neuropathy pain, opioid use disorder, muscle stiffness/tremors, aggressive behaviors, agitation, and depression, even though these conditions were not consistently listed in their medical records or the indications were not clinically appropriate. In addition, residents on psychotropic medications, including antipsychotics and antidepressants, were not consistently monitored for side effects, behaviors, or sleep patterns as ordered or expected, despite ongoing administration of these medications. The DON confirmed these discrepancies between indications, diagnoses, and monitoring.
Surveyors found that two residents were receiving medications without appropriate indications based on their documented diagnoses. One resident, whose conditions included heart disease, Alzheimer’s disease, DM2, and CKD, had an order for apixaban twice daily for A-fib despite having no A-fib diagnosis. Another resident, diagnosed with DM2, bipolar disorder, HTN, COPD, and RA, was ordered memantine and Aricept at bedtime for Alzheimer’s disease, although this diagnosis was not present in the record. The DON confirmed in interviews that these residents did not have the diagnoses for which the medications were ordered and stated that medications should only be ordered and administered for conditions the residents actually have.
A resident admitted with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism was prescribed and administered Carbidopa-Levodopa at bedtime with an indication of Parkinson’s disease, despite not having a Parkinson’s diagnosis. Review of the MAR showed the medication was given on multiple consecutive days, and the IDON confirmed that the documented indication did not match the resident’s current diagnoses, resulting in a deficiency related to unnecessary medications.
Failure to review pharmacy recommendations and implement GDRs for multiple residents. The facility did not complete required monthly pharmacy reviews for several months, and provider review of consultant pharmacist recommendations was delayed or absent for residents receiving psychotropic and other medications, including aripiprazole, lorazepam, quetiapine, escitalopram, hydroxyzine, and trazodone. The DON stated pharmacy recommendations were expected to be reviewed by a provider within a couple of days, but several were not acknowledged.
Surveyors found that three residents were receiving medications whose indications did not match their current diagnoses. One resident with insomnia, major depressive disorder, and a psychotic disorder was routinely given cetirizine for seasonal allergies and acetaminophen and tramadol for pain, despite not having allergy or pain diagnoses. Another resident with schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety was administered weekly methotrexate ordered for rheumatoid arthritis, although no RA diagnosis was present. A third resident with major depressive disorder, insomnia, anxiety, hyperlipidemia, and heart failure received daily Zyrtec via G-tube for allergies without an allergy diagnosis. In each case, the DON confirmed that the indications for these medications did not correspond to the residents’ documented conditions or related symptoms.
Surveyors found that multiple residents were receiving medications without clear, diagnosis-based indications or complete orders. Several residents had aspirin ordered daily with indications such as “preventative” or “prophylactic,” which the DON acknowledged were not appropriate or specific indications. One resident had a probiotic ordered without a stated purpose, missing dosage, and a mismatch between the ordered form and the form to be administered. Other residents were prescribed medications such as potassium chloride, atorvastatin, Colace, cetirizine, cephalexin, furosemide, and naloxone without corresponding active diagnoses (e.g., hypokalemia, hyperlipidemia, constipation, allergies, UTI, edema, or opioid use) documented in their records, and the DON confirmed that these orders did not align with the residents’ listed diagnoses.
A resident with a history of venous thrombosis and embolism was receiving rivaroxaban for anticoagulation, and a pharmacist had recommended monitoring for bleeding and thromboembolism as potential side effects. Review of the medical record showed no documentation that staff monitored for these anticoagulant side effects. An LPN and a Regional Clinical Nurse both confirmed that nurses were expected to monitor and document anticoagulant side effects in the MAR, yet acknowledged that no such documentation existed for this resident.
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