A resident on warfarin for a mechanical heart valve had critically elevated PT/INR values documented, yet nursing staff continued to administer warfarin, including during a period when the drug was ordered to be held. The MAR shows doses given on days when INRs were elevated, with no evidence that the physician was notified before administration. After a critically high INR, the provider ordered vitamin K and daily PT/INR labs for two days, but the ordered labs were not drawn as scheduled, and the next INR was not obtained until after the resident became nonresponsive and stopped eating. The DON later confirmed that the labs were missed and that there was no documentation of timely physician contact regarding the elevated INRs.
Surveyors found that nurses failed to follow physician-ordered vital sign parameters for antihypertensive medications for two residents. One resident with multiple chronic conditions, including essential hypertension and mild cognitive impairment, received metoprolol doses despite heart rates below the ordered hold threshold. Another resident received hydralazine even when systolic blood pressures were outside the specified parameters. Nursing staff acknowledged administering these medications outside the prescribed limits, and the DON confirmed that facility policy requires medications to be given in accordance with physician orders and associated vital sign checks.
A resident with a prosthetic heart valve on warfarin therapy had significantly elevated INR values, yet nursing staff continued to administer warfarin without documented physician notification or guidance and in conflict with hold orders. PT/INR monitoring was ordered but not consistently completed as prescribed, including missed ordered labs on consecutive days, and there was no evidence of staff follow-up with the lab to ensure testing occurred. The resident subsequently exhibited lethargy, decreased responsiveness, and poor oral intake, leading to further evaluation and hospital transfer, and the DON later confirmed the lapses in lab monitoring and lack of documented provider contact.
A resident had an order for midodrine 5 mg three times daily with instructions to hold the dose if systolic BP exceeded a specified parameter. Review of the MAR showed 13 documented administrations of midodrine outside these ordered parameters. Two LPNs reported that they always check BP before giving parameter-based medications and believed the entries were documentation errors, while the DON stated that nursing staff are expected to follow physician orders, including specific parameters. The discrepancy between the physician order and the documented administrations resulted in a deficiency related to unnecessary drugs.
A resident receiving Seroquel for psychosis had an AIMS documented with a score of 0.0, but the facility did not complete the quarterly monitoring when it was due. The resident had diagnoses including dementia, psychotic disturbance, MDD, and anxiety, and the ADON acknowledged the AIMS should have been done quarterly.
A resident with chronic pain and multiple diagnoses was given Tramadol for pain levels below the physician-ordered threshold. The MAR showed the medication was administered for pain scores of 4 and 5, despite orders specifying use only for pain levels 6 to 10. Interviews with the DON, Medical Director, and an LPN confirmed that medication was given outside of prescribed parameters, and relevant policies were not provided during the survey.
A resident with multiple chronic conditions was given Oxycodone-Acetaminophen for pain levels below the physician-ordered threshold. The medication was administered for pain scores of 3, 5, and 6, despite orders specifying use only for severe pain rated 7-10. Facility staff, including the DON and an RN, confirmed that the medication was given outside the prescribed parameters and without notifying the provider or obtaining a new order.
A resident with multiple medical conditions received Metoprolol despite physician-ordered parameters to hold the medication for low systolic blood pressure. Medication records showed repeated administration of the drug when blood pressure readings were below the specified threshold. Interviews with LPNs revealed a lack of adherence to the parameters, and facility policy requiring medications to be given as prescribed was not followed.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account