A resident with schizophrenia, depression, type 2 DM, and a court-appointed guardian had a new physician order allowing LOA transcribed by an LPN, but the guardian was not notified when the order was written. The LPN confirmed the omission, RN confirmed guardians should be notified of new orders, and the DON stated the guardian was notified, while the facility had no documentation of prior guardian permission for the resident to leave the facility.
A resident with dementia and severe cognitive impairment was given psychotropic medications including Xanax, Zoloft, Depakote, Remeron, and Trazodone, but the record showed no evidence that the resident’s representative was notified of or assisted with consent. The original consent was completed despite the resident’s impaired cognition, and it was not updated when additional psychotropic medications were added; the DON confirmed the consent issue and was unsure whether the son had been notified.
Failure to obtain informed consent before psychotropic medication use. A cognitively intact resident with morbid obesity, DM2, and a L femur fracture received buspirone for anxiety and duloxetine for depression as ordered, but the Psychotropic Medication Administration Disclosure was not completed until after the meds had already been administered. RN confirmed the disclosure was not done at admission or before treatment, despite the facility policy requiring informed consent and documentation before psychotropic use.
Failure to Obtain Guardian Consent for Pharmacogenomics Testing: The facility did not obtain guardian consent for pharmacogenomics testing for four residents. The residents had court-appointed guardians, and the consent forms were not signed by the guardian. The guardian and the Administrator both confirmed the missing consent, and the facility policy stated legal representatives should be informed of the care and services provided.
A resident with dementia, glaucoma, and cataracts had long-standing scheduled orders for Brimonidine and Latanoprost eye drops, consistent with an ophthalmology visit summary and a care plan goal to prevent negative consequences of vision loss. The physician orders were later changed from scheduled to PRN administration, but review of the EMR and nursing notes showed no documentation that the resident’s representative was informed of this change. In an interview, the representative stated she was upset about not being notified, and a regional nurse consultant confirmed there was no evidence that either the resident or the representative had been informed, resulting in a cited deficiency related to failure to ensure the resident and representative were fully informed about changes in treatment.
The facility failed to notify residents of a change in Medical Director or give them a choice of physician, and failed to respect a resident’s choice in diabetes management. A resident with type 2 DM and other significant diagnoses had his continuous glucose monitor removed without documentation of notification, rationale, or choice, and staff confirmed residents were automatically changed to the new MD without being asked if they wanted to keep their current physician or choose another provider.
Failure to obtain informed consent for psychotropic medications: A resident with cancer diagnoses, depression, and anxiety had orders for an SSRI and PRN benzodiazepine, but the record lacked documentation that the resident or representative was educated on the risks and benefits needed to provide informed consent. The DON confirmed the missing consent documentation and stated the prior consents should have been completed on admission.
Two residents with cognitive and behavioral disturbances received IM Haldol for acute episodes of agitation, paranoia, and physical aggression after refusing PO medications and nonpharmacological interventions were ineffective. In both cases, providers ordered one-time IM Haldol doses on multiple occasions, and family members were notified of the orders and involved in communication about the residents’ behaviors and treatment. One resident’s family later filed a grievance regarding IM Haldol use, and informed consent was documented only for Trazodone. Facility leadership confirmed there was no documentation that the risks or side effects of Haldol were discussed with either resident or their responsible parties prior to administration.
A resident with multiple medical conditions, including metabolic encephalopathy and Generalized Anxiety Disorder, was started on BuSpar 10 mg BID following a psychiatric evaluation, but the responsible party was not properly informed of this new psychotropic medication order. Nursing notes lacked documentation of the psychiatrist’s assessment or any notification to the responsible party, even though the MAR showed the resident received two doses. The responsible party later reported learning of the medication only during an in-person visit and expressed concern due to the resident’s prior adverse reactions to psychotropic drugs. Conflicting accounts from two ADONs about when and how the responsible party was notified, combined with the absence of required documentation, demonstrated noncompliance with the facility’s policy on notifying and documenting changes in a resident’s condition or treatment.
Missing Signed Consent for Psychotropic Medications: A resident with schizo-affective disorder, dementia, bipolar disorder, major depressive disorder, and anxiety received psychotropic meds including Duloxetine, Remeron, and Clonazepam. The record showed signed consent for some antipsychotics, but the consent form for Duloxetine and Remeron was not signed by the resident, and the DON and RN confirmed there was no documented signed consent showing the risks and benefits had been explained for those meds.
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