Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Two residents did not receive necessary care and services when ordered medications and bowel interventions were not provided as prescribed. One resident with hypertension, hypothyroidism, and weight loss missed doses of appetite stimulant and thyroid medication, and received an anti-hypertensive even when BP readings were outside ordered parameters, with additional doses omitted. Another resident with uterine cancer and constipation had no documented bowel movements for several days, repeatedly complained of constipation, and had a PRN bisacodyl suppository ordered but never administered, despite a facility bowel protocol and subsequent imaging showing significant bowel issues.
A resident with HTN, atrial fibrillation, and end-stage renal disease had a physician order for midodrine with instructions to hold the dose if systolic BP was greater than 130 mm Hg. Review of the clinical record showed that staff repeatedly administered midodrine when the resident’s systolic BP readings were above this parameter, including significantly elevated values, without documented reasons for not following the order. The resident’s care plan identified risk for medication side effects and directed that medications be given per physician orders, and facility policy required adherence to all physician orders with documentation of any deviations, but these requirements were not followed.
Failure to apply ordered tubi grip to a resident’s bilateral arms for edema. The resident was observed with swollen lower arms and at times did not have the tubular sleeves in place, despite a physician order and care plan directing tubi grip to both arms in the morning and off at bedtime. The resident stated he had never refused the sleeves and that they provided some relief from the swelling; the DON stated the nurse was responsible for applying them.
A resident with chronic venous insufficiency developed a large blister on the right foot with redness, warmth, tenderness, edema, and concern for cellulitis. The chart showed an order for linezolid and wound care with Xeroform, ABD, and kerlix, but the antibiotic was not given for several scheduled doses and the Xeroform order was missing from the record. The resident was observed with an unraveling dressing and drainage, and an LPN was unsure why only 2 of 10 antibiotic doses had been administered.
Failure to Hold Medications Outside Ordered Vital Sign Parameters The facility administered BP and diabetes medications outside physician-set hold parameters for multiple residents. Metoprolol, midodrine, and insulin were given or managed without following ordered SBP, DBP, pulse, or blood sugar limits, and MD/NP notification was not documented when required. Staff interviews confirmed that medications should be held when vital signs are outside the ordered parameters and the physician notified.
The facility failed to follow physician orders for daily weights and medication hold parameters for several residents. A resident with CHF missed ordered daily weights, another resident had significant weight gains without physician notification, and a resident with BP-related PRN orders had multiple missed administrations when BP was outside ordered parameters. Another resident received metoprolol multiple times despite diastolic BP readings below the hold limit, even though staff interviews and facility policy stated orders with parameters should be checked before administration.
Surveyors found that staff repeatedly administered antihypertensive medications to two residents despite physician orders to hold the drugs when BP readings were below specified parameters, as documented on multiple MARs. A resident on antiplatelet therapy, care planned as at risk for bruising, was observed with multiple purple and red bruises on both arms, yet there were no corresponding physician orders to monitor bruising, no nursing documentation of the bruises over a documented period, and a missed weekly skin assessment. Another resident with vascular disease and cellulitis, care planned and ordered to have heel boots on at all times with heel checks every shift, was repeatedly observed without heel boots in place while MAR entries indicated they had been applied, and the resident reported he was also supposed to have compression socks that were not provided.
The facility failed to administer a resident's midodrine according to the ordered BP parameters; the MAR showed doses missed when BP was within range and a dose given when BP was above the hold parameter, and the DON stated the nurse had read the order wrong. The facility also failed to follow a physician order for another resident's Tubigrips for edema, as the resident was observed without compression wraps while in bed and later wearing only non-slip socks, despite the treatment record showing the wraps as administered.
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