Psychotropic Medications Lacked Targeted Behaviors and Monitoring: A resident with Alzheimer’s dementia, CHF, and parkinsonism received Olanzapine and Trazodone, but the record did not identify targeted behaviors or document individualized interventions to support use of the meds. The chart showed limited behavior notes, no documented side effect monitoring on the MAR, no sleep/insomnia monitoring, and no evidence the psych NP saw the resident after admission.
Failure to Attempt GDR for Lorazepam: A resident with anxiety, depressive disorder, and altered mental status remained on Lorazepam 0.25 mg BID for anxiety despite pharmacy recommendations to reduce the dose to daily and no documented behaviors on monitoring reports. The FNP agreed with the dose reduction recommendation, but the order was not entered in the resident record, and the DON stated the change order should have been entered by the DON.
Failure to Document Behaviors Supporting Antipsychotic Use: The facility did not identify and track targeted behaviors or individualized interventions to clinically support antipsychotic use for two residents. One resident with dementia, anxiety, delusional disorder, and sexually inappropriate behaviors had repeated yelling out and PRN anxiolytic use, but the record often showed no delusions or hallucinations and lacked documentation of nonpharmacologic interventions before PRN doses. Another resident with bipolar disorder, depression, PTSD, and delusional disorder received Seroquel despite MDS and psych notes showing no hallucinations or delusions during multiple periods, and the record lacked behavior tracking to support the medication.
A resident received Seroquel 100 mg twice daily for anxiety disorder/agitation, but the record did not show an approved diagnosis for the antipsychotic. The resident was cognitively intact, psychiatry was ordered but not completed, and the DON stated there was no approved diagnosis for the Seroquel use.
A resident with Parkinson’s disease, dementia, anxiety, visual impairment, and a history of restlessness and resistive care received quetiapine without documented specific delusions or hallucinations to support its use. The chart and care plans did not identify targeted psychotic behaviors or individualized non-pharmacological interventions, even though the resident was often observed sitting quietly, sleeping, or appearing calm, while other notes described intermittent agitation, attempts to stand or climb out of bed, and occasional hitting or kicking during care.
A resident with a history of TBI, depression, anxiety, and dementia continued to receive risperidone for depression and later for a delusional disorder despite repeated assessments showing no delusions, hallucinations, or behavioral symptoms and staff and family reporting no such issues. Pharmacy reviews documented that there was no appropriate diagnosis to support antipsychotic use and that risperidone is not indicated for depression, yet the medication was continued with only one gradual dose reduction and later recommendations for further GDR declined or deferred. Although psychiatry suggested non-pharmacological interventions such as cognitive/emotion-oriented therapies, sensory stimulation, and behavior management techniques, the record contained no evidence that these interventions were developed or implemented, contrary to the facility’s psychotropic medication and GDR policy.
Surveyors found that prescribers failed to document individualized clinical rationales and to sign and date consultant pharmacist recommendations when declining suggested changes to psychotropic medications for three residents with dementia, anxiety, depression, insomnia, and psychotic disturbance. In each case, the pharmacist recommended gradual dose reductions or dose adjustments of antipsychotic, antianxiety, or sedative medications, but the declinations lacked written justification on the recommendation forms, and in two instances the forms were not signed or dated by the prescriber, despite facility policy requiring an explanation when rejecting pharmacist suggestions.
PRN psychotropic orders were left open-ended for three residents. Two residents had lorazepam orders without a stop date, including one resident on hospice, and another resident had a hydroxyzine PRN order without a stop date. The DON stated non-hospice meds should have a 14-day stop date, and hospice orders should specify the duration of hospice; the facility policy also required PRN psychotropic orders to be limited to no more than 14 days unless the prescriber documented a rationale and specific duration.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antipsychotic Use: A resident with dementia, mood disorder, and metabolic encephalopathy received PRN quetiapine multiple times for agitation, psychotic behaviors, and psychosis related to dementia. The MAR, nurse's notes, and behavior notes contained no documentation that non-pharmacological interventions were attempted before several doses, and the DON acknowledged they should have been tried first.
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