A facility failed to document an appropriate indication and physician rationale for continued antipsychotic use for two residents. One resident with dementia and behavioral disturbance and another resident with Alzheimer’s disease and hallucinations were receiving Seroquel, but their records lacked documentation of unsuccessful nonpharmacological interventions and a risk-versus-benefit rationale for the medication. Observations showed an LN administering the residents’ medications, and the RN later verified both residents were receiving Seroquel.
Failure to document rationale for no GDR of psychotropic meds. A resident with anxiety, depression, and dementia had orders for duloxetine, quetiapine, and haloperidol, and the MDS showed severely impaired cognition. Pharmacy review requested documented rationale for GDR recommendations, but the prescriber marked no change without explaining why no GDR would be attempted. Observations showed the resident resting in bed with no combative behavior or resistance during care.
A resident with dementia, vascular dementia, mood disorder, and major depressive disorder received risperidone with changing indications documented in the EMR, including mood disorder, adjunct to depression, agitation, and psychosis with delusions. The chart lacked documentation of multiple unsuccessful nonpharmacological interventions and a clear risk-benefit rationale for continued antipsychotic use, and the care plan was not revised to reflect new interventions. Nursing leadership stated no nonpharmacological approaches had been tried, while pharmacy/provider notes questioned the non-FDA-labeled indication and requested GDR review.
A resident with anxiety, cerebral palsy, and dementia with delusions/hallucinations had a PRN Ativan order that was continued without the required stop date or documented physician rationale for extending it beyond 14 days. The resident’s care plan included multiple psychotropics, and staff stated the order was called in every two weeks but still lacked a stop date and rationale, contrary to facility policy.
A resident with Alzheimer’s disease, depression, and moderately impaired cognition received Seroquel and Xanax, but the EMR lacked a documented physician rationale for the antipsychotic, including risk-versus-benefit review and unsuccessful nonpharmacological attempts. The care plan and psychotropic CAA documented the medications and related diagnoses, while staff interviews confirmed the antipsychotic indication was not questioned and was known to be incorrect.
PRN lorazepam orders for two residents with anxiety lacked required stop dates. One resident had intact cognition and documented antianxiety medication use, while the other had documented psychotropic use and impaired cognition; both had care plans to monitor for side effects, and an RN confirmed the orders did not include the stop date required by facility policy for PRN psychotropic meds.
Failure to Monitor Hypnotic Medication: A resident with insomnia and major depressive disorder received nightly zolpidem (Ambien), but the MDS and psychotropic CAA did not accurately document the hypnotic use or insomnia diagnosis. The care plan referenced Ambien and monitoring needs, yet the EMR lacked evidence of ongoing monitoring for side effects and effectiveness, and staff stated there was no reminder to monitor the medication or document its effectiveness.
A facility failed to obtain stop dates for PRN lorazepam orders for two residents receiving psychotropic meds. One resident had anxiety and severe cognitive impairment, and another had anxiety disorder, dementia, and hospice status with moderately impaired cognition and delusions. Both residents had lorazepam PRN orders without stop dates, and one resident received the medication multiple times over the month. An RN confirmed the missing stop dates, and the facility’s psychotropic medication guidance required a 14-day stop date for PRN psychotropics.
A facility failed to document stop dates for PRN lorazepam/Ativan orders for three residents with dementia, anxiety, and other cognitive or behavioral issues. The records showed the PRN psychotropic orders lacked the required 14-day limit or documented prescriber rationale for extended use, and staff verified the missing stop dates in the EMR.
A facility failed to include a 14-day stop date or documented physician rationale for a PRN lorazepam order for a resident with anxiety and severe cognitive impairment. The facility also failed to document monitoring for Abilify in another resident with MDD and anxiety; the care plan and EMAR lacked documentation of target behaviors, side effects, interventions, and effectiveness, despite policy requiring monitoring of psychoactive meds every shift.
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