A resident with bipolar disorder, depression, anxiety, and OCD was receiving multiple psychotropic medications, including an antidepressant, an antipsychotic, and two antianxiety medications. Although the care plan called for monitoring side effects and adverse reactions, the EMR had no documentation of side effect tracking or a recent AIMS test, and the RN/Unit Manager confirmed both were missing. The DON stated the expectation was for quarterly AIMS testing for residents on antipsychotics and side effect monitoring documented on the MAR/TAR.
Missing stop date for PRN psychotropic medication: A resident with a seizure disorder had a PRN lorazepam IM order for seizure activity that remained active without a required stop date. The facility policy required PRN psychotropic orders to have a set duration, and staff, including an LPN/Unit Manager and the DON, confirmed the order lacked the 14-day stop date.
Missing Stop Date for PRN Psychotropic Medication: A resident received PRN Klonopin repeatedly without the required 14-day stop date. The MD order for clonazepam had no stop date, and the MAR showed multiple administrations over the review period. The ADON and DON both acknowledged the oversight and confirmed the medication should have had a 14-day stop date.
Surveyors found that the facility did not properly obtain or document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral disturbances was receiving Depakote ER for mood and agitation without any signed consent or documented risks vs benefits. A second cognitively intact resident with multiple psychiatric diagnoses was on four psychoactive medications (Klonopin, Abilify, Sertraline, Quetiapine); although a consent form was signed and witnessed due to the resident’s physical limitations, the form lacked required details such as specific drugs, dosages, frequencies, targeted behaviors, and potential side effects. A third severely cognitively impaired resident with dementia and other psychiatric conditions was receiving Valproate Sodium for behaviors without any signed consent or documented discussion of risks and benefits. The DON acknowledged that consents for these residents could not be located, despite a facility policy requiring such information and documentation before initiating or increasing psychotropic medications.
Missing Stop Dates for PRN Psychotropic Medications: A resident with vascular dementia and severe agitation had PRN psychotropic orders for Ativan and Haldol entered without end dates. The consultant pharmacist had notified the physician that PRN antipsychotics require a hard 14-day stop unless the order is rewritten after a physical assessment, but the orders remained without stop dates. The MDS Coordinator, DON, LPN, RN, and physician all confirmed the missing end dates, and staff stated the medications were part of a hospice comfort pack.
A resident with depression, anxiety, and other medical conditions received PRN alprazolam for anxiety beyond the 14-day limit required by facility policy. The order was entered with an indefinite stop date, and the medication was administered on multiple occasions past the allowed timeframe. Staff confirmed the expectation for a 14-day limit on PRN psychotropic medications, but the order and administration did not comply with this policy.
A resident reviewed for unnecessary medications received buspirone 15 mg BID for "nerves," even though the MDS showed full cognition and no active anxiety disorder diagnosis. The DON verified the order was documented for nerves, said the VA discharge orders used that wording, and stated the nurse who reconciled medications was expected to enter the order as received; the facility's physicians did not have involvement with respite residents' medications because they brought medications from home with the indication of use.
Failure to Monitor Psychotropic Medication Behaviors and Side Effects: The facility failed to ensure that psychotropic medications were monitored for target behaviors and side effects for two residents. One resident with Parkinson’s disease and schizophrenia received Haldol without orders or documentation for behavior or side-effect monitoring, and another resident with stroke history, depression, anxiety, insomnia, and vascular dementia with agitation received trazodone, Ativan, and Haldol without monitoring for side effects related to the antianxiety and antipsychotic medications. The DON confirmed the missing monitoring on the MAR/TAR.
Two residents continued to receive psychotropic medications at unchanged doses despite recommendations and facility policy requiring gradual dose reductions (GDR). For one resident, lorazepam was not reduced as ordered by the Medical Director, and for another, olanzapine was not tapered despite no recent behavioral symptoms. In both cases, staff responses to pharmacist GDR requests lacked resident-specific clinical rationale, and documentation did not justify the ongoing medication regimens.
Two residents prescribed psychotropic medications did not have required behavior monitoring documented every shift as ordered by their physicians. Despite clear orders and care plans, multiple dates were identified where staff failed to record behavioral observations, and interviews with nursing staff and the DHS confirmed that this documentation is a standard responsibility for each shift.
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