Failure to Monitor and Report TD Symptoms: A resident receiving antipsychotic medications was observed with repeated lip smacking and other involuntary movements consistent with TD. Nursing staff documented the symptoms multiple times, and an AIMS assessment showed prominent facial, oral, and lower extremity movements with mild distress, but the physician was not notified and there was no record of recent psych/behavioral health follow-up related to the symptoms.
Psychotropic Medication Monitoring and Care Planning Deficiencies: Surveyors found that two residents had psychotropic medication use that was not monitored or reviewed in a resident-specific way. One resident with dementia, anxiety, depression, and a recent femur fracture had antipsychotic and sleep medications ordered without documentation of resident-specific behaviors, effective interventions, or person-centered non-pharmacological approaches in the care plan. Another resident with Parkinson’s disease, anxiety, and depression had antidepressant and anti-anxiety medication orders with generic behavior and intervention templates that were not individualized, and the record did not show what interventions were used or whether they worked.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Two residents remained on duloxetine without timely action on pharmacist-recommended GDRs, and the facility did not address the recommendations for about two months. One resident had COPD, anxiety, dysphagia, and moderate cognitive impairment, while the other had COPD, dementia, depression, and severe cognitive impairment. The DON stated monthly pharmacy recommendations were reviewed and sent to the medical director, but the record showed delayed follow-up and no specific documentation of medication modification requests for one resident.
A resident with dementia and bipolar disorder was given olanzapine, but the pharmacist and physician recommended a GDR without documentation that the resident’s representative was informed before the change was implemented. Another resident with Alzheimer’s disease, depression, insomnia, and PTSD had repeated agitation and exit-seeking while receiving multiple psychotropic medications, but the IDT review of sertraline was not clearly documented and the care plan lacked resident-specific non-pharmacological interventions or clear behavior monitoring details.
Failure to Reevaluate PRN Psychotropic Medication: A resident with vascular dementia, restlessness, agitation, and severe cognitive impairment received PRN lorazepam under an order written for 90 days. The record showed the PRN psychotropic was not reevaluated after the 14-day limit and no physician rationale was documented to justify continued use beyond that period, despite doses being administered during the month.
A resident with mood disorder, anxiety, vascular dementia, and depression was prescribed sertraline, but the EMR had no documentation of behavior monitoring, side effect monitoring, or effectiveness monitoring. Staff reported the resident yelled out, moved tables, hit staff, and slept most of the time, yet the resident was not added to the alert charting binder and had no care plan for psychotropic monitoring.
Unreviewed psychotropic medication use without documented GDR consideration. A resident with dementia, cognitive impairment, wandering, and prior behaviors remained on Seroquel for dementia with behaviors, but the record did not show quarterly IDT review of continued need or GDR consideration. Observations showed the resident sleeping in bed while activities were offered to others, and the chart lacked documentation addressing PHQ-9 findings or follow-up for mood concerns. MAR/TAR review showed no documented behaviors during the review period, yet the psychotropic medication continued without documented IDT justification.
A resident with Lewy body dementia, parkinsonism, and anxiety received PRN lorazepam and Seroquel without the facility enforcing the 14‑day limit for PRN psychotropic orders or obtaining documented physician reevaluation and rationale for continuation beyond that period. Pharmacy reviews had recommended 14‑day stop dates and behavior tracking for psychotropics, but these were not timely implemented, and the EMR lacked consistent behavior and side‑effect monitoring orders or documentation for the resident’s lorazepam and Seroquel. Nursing and leadership staff reported that they typically monitor behaviors and side effects for psychotropic use and understood that PRN psychotropics should not exceed 14 days, yet the DON confirmed that behavior and side‑effect monitoring orders were missing for this resident and that new medication orders were not being reviewed daily.
A resident with dementia, COPD, pneumonia, and mild depression was prescribed an antidepressant, an antianxiety medication, and an antipsychotic, but the record did not show documented behaviors to justify the antipsychotic use. The care plan lacked specific target behaviors, the MARs did not include mood or behavior tracking or side effect monitoring for the antipsychotic and antianxiety meds, and the chart did not contain consent documentation for the psychotropic medications.
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