Surveyors found that two residents had duplicate PRN medication orders without clear instructions on which route to use first. One resident with severe dementia and constipation had multiple bisacodyl orders (scheduled oral tablets, PRN oral tablets, and a PRN suppository) on the MAR, with no indication of sequencing, while the care plan referenced prune juice and PRN Dulcolax use. Another resident with dementia, a sacral fracture, and chronic pain had both PRN rectal acetaminophen and scheduled oral acetaminophen ordered, again without guidance on which to administer first. The DON stated that the least invasive or oral options should be used first and acknowledged that the rectal PRN orders were likely unnecessary, but they remained active in the residents’ drug regimens.
A resident with a history of stroke-related hemiplegia, seizure disorder, and dementia continued to receive tamsulosin (Flomax) 0.4 mg at bedtime for kidney stones and prior stent removal, despite no current urological diagnosis. Facility records and the DON’s interview confirmed the resident’s kidney stone treatment and ureteral stent occurred before admission, and there had been no subsequent treatment or active urological condition. National Library of Medicine guidance cited by surveyors indicated tamsulosin for ureteral stones is typically used for a limited duration, yet the medication order remained in place without an appropriate, documented indication, resulting in an unnecessary drug regimen for the resident.
Surveyors found that the facility did not prevent duplicate medication orders or ensure monitoring for medication side effects for two residents. One resident on palliative care with CHF and acute kidney disease had two PRN orders for lorazepam oral concentrate written for the same dose and frequency, one for anxiety and one for terminal agitation, with no documented monitoring for sedation, respiratory status, cognitive changes, or other adverse effects despite FDA guidance. Another resident with diabetes, CHF, and mild cognitive impairment had two overlapping PRN orders for bisacodyl suppositories, which the CRN acknowledged were in error.
A resident with acute osteomyelitis of the left ankle and foot had PRN orders for acetaminophen for mild pain and Percocet for moderate to severe pain. Documentation showed acetaminophen was given only once for a pain level of 4 and then not administered for several days, while Percocet was administered multiple times for documented pain levels of 3, below the ordered indication for moderate to severe pain. The facility’s pain management policy required pain assessment every shift with documentation of the pain scale and type of pain, and the DON reported that physicians had moved away from relying on the numeric pain scale because residents might underreport their pain.
Surveyors found that two residents receiving Depakote for conditions including alcohol dependence, borderline personality disorder, Alzheimer’s disease, and suicidal ideations were not monitored for anticonvulsant side effects as required by their person-centered care plans. Although the care plans directed staff to monitor, notify the provider, and document specific symptoms such as over-sedation, agitation, confusion, mental status changes, visual disturbances, gait changes, behavioral changes, and weight changes, the clinical records contained no documentation of such monitoring. The DON confirmed that anticonvulsant monitoring was not present in the records, and the report noted this failure created the potential for harm if side effects were undetected.
A resident with lumbar spinal stenosis and neurogenic bladder had a physician order for Gentamicin Sulfate bladder irrigation that lacked a documented indication or diagnosis and specified an indefinite duration. Facility policies required all medication orders to include an indication or diagnosis and duration, and to ensure regimens were free from unnecessary medications. Review of the order and an interview with the ACNO confirmed that these required elements were missing, resulting in noncompliance with the facility’s own medication and unnecessary drug policies.
A resident with osteomyelitis and sepsis had PRN oxycodone orders specifying one tablet for moderate pain and two tablets for severe pain, based on a standard pain scale. MAR review showed staff repeatedly administered the higher, two-tablet dose when the documented pain scores reflected only mild to moderate pain. The DNS confirmed that the facility uses the standard pain scale and that the opioid should have been given according to the ordered pain levels but was not, resulting in the resident receiving opioid doses inconsistent with the prescribed indications.
A resident with COPD and incomplete quadriplegia was maintained on a daily nicotine transdermal patch and had a PRN order for nicotine gum while also continuing to smoke cigarettes. The MAR showed the patch was administered, and the DON reported the resident was an infrequent smoker but could not provide documentation of infrequent smoking during the period when nicotine replacement therapy was in place. Surveyors found this combination of active nicotine replacement orders and ongoing smoking did not ensure the resident’s drug regimen was free from unnecessary medications and placed the resident at risk for adverse outcomes from overmedication.
A resident with multiple medical conditions was given lorazepam, an anti-anxiety medication, on two occasions without any documented symptoms or behaviors of anxiety. The DON confirmed that the medication was administered without the necessary documentation to support its use as required.
A resident with a right above-knee amputation and diabetes had PRN orders for acetaminophen for pain rated 1–5 and Percocet for pain rated 6–10, with a maximum of four doses per day. MAR review showed Percocet was administered multiple times for documented pain levels of 4–5, which did not match the ordered indication. The DON acknowledged that the pain medication should have been administered according to the specified pain levels but was not, resulting in opioid use without adequate indication as required by the facility’s unnecessary drugs policy.
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