A resident with Alzheimer’s disease, severe cognitive impairment, depression, anxiety, delusions, and behavioral symptoms was receiving lorazepam both as a scheduled dose and PRN every four hours for restlessness and agitation, including a topical form if oral medication was refused. Physician orders for the PRN lorazepam lacked stop dates, and although the consultant pharmacist recommended a stop date or GDR, the physician declined, citing hospice and palliative care without specifying a duration. The nurse overseeing psychotropic use confirmed the absence of a stop date and uncertainty about requirements for palliative residents, despite facility policy mandating that PRN psychotropic medications (other than antipsychotics) be limited to 14 days unless a longer timeframe is explicitly ordered. This resulted in a deficiency related to unnecessary psychotropic medication management.
Surveyors identified that two residents with dementia, depression, and anxiety were receiving daily antipsychotic medications without documented physician rationale or risk–benefit analysis for their continued use with non-approved indications. Each resident’s MDS showed severely impaired cognition and ongoing psychotropic use, while their care plans only directed staff to administer medications as ordered. Physician orders specified olanzapine for behaviors or a psychotic disorder, but the EMRs lacked documentation of multiple unsuccessful nonpharmacological interventions and risk–benefit considerations, and the available psychoactive medication consent forms did not contain the required physician justification, contrary to facility policy on psychotropic drug use.
PRN Psychotropic Medication Lacked Required Stop Date: A resident with anxiety, depression, gastroparesis, GERD, and nausea had a PRN clonazepam order for anxiety, but the record lacked a 14-day stop date or specific end date. The resident had intact cognition, was noted in a recliner during morning med pass, and an RN confirmed the PRN order was routinely used twice daily and had no stop date, despite the facility policy limiting PRN psychotropic use to a limited duration unless otherwise documented.
A resident with hypertension, DM, severely impaired cognition (BIMS 0), and dependence in most ADLs was receiving multiple psychotropic medications, including an antianxiety agent. The EMR contained an order for lorazepam cream 0.5 mg to be applied every eight hours and PRN for dementia, but the order did not include the required 14-day stop date or any specified duration, and there was no physician rationale documented for extended PRN use. Staff interviews indicated that nurses were expected to notify physicians that PRN lorazepam required a stop date and that the DON was a second check for orders, yet this did not occur, and the facility was unable to provide its unnecessary psychotropic drug policy when requested.
Unclear indication for continued antipsychotic use: A resident with dementia, mood disturbance, anxiety, and severely impaired cognition received Seroquel for a mood disorder, but the record did not show an appropriate indication or documented physician rationale for continued antipsychotic use. The EMR listed excessive aggression during cares as the indication and noted non-pharm approaches such as retrying care later or using a different caregiver; staff observed the resident receiving the AM dose, and an admin nurse confirmed the antipsychotic was being given.
A resident with dementia, anxiety, and severe cognitive impairment was found to have two PRN lorazepam orders that lacked the required 14-day stop date or a specified duration with supporting physician rationale. The resident’s record also documented antipsychotic, antidepressant, and antianxiety use, along with behaviors such as verbal and physical aggression, yelling obscenities, and hitting. An RN verified the PRN orders did not include the required stop date or duration.
A resident with schizoaffective disorder missed an ordered Invega Sustenna dose, and the chart lacked a nursing note or rationale for the omission. Another resident with Alzheimer’s disease and other psychiatric diagnoses remained on Seroquel without documented physician rationale, unsuccessful nonpharmacologic attempts, or a risk-versus-benefit review. Staff interviews confirmed the first resident’s refusal process was expected to be documented and that the second resident had no behaviors and stayed in her room most of the time.
A resident with Alzheimer’s disease, prior stroke, insomnia, and major depressive disorder was maintained on Quetiapine for “unspecified dementia with psychotic disturbances” without a CMS-approved indication and without behavioral monitoring. The MDS showed severe cognitive impairment but no documented behaviors, and the care plan referenced resisting care and yelling out but did not include a clear psychiatric indication for antipsychotic use. The resident was observed calm and behavior-free, while the EMR lacked behavior tracking tied to the antipsychotic. A consultant pharmacist recommended gradual dose reduction, which the provider declined, and staff acknowledged that antipsychotics are not indicated for dementia alone and that the resident’s representative refused medication changes, leaving the facility unable to document an appropriate rationale consistent with its own psychotropic medication policy.
A facility failed to ensure two residents had PRN psychotropic medication orders with required 14-day stop dates or a documented duration with physician rationale. One resident had PRN haloperidol and lorazepam orders without stop dates, and another had a PRN trazodone order without a stop date. Staff stated PRN psychotropic orders required 14-day stop dates, and the facility policy reflected that requirement.
Surveyors found that the facility did not ensure appropriate indications and documentation for psychotropic medications. A resident with dementia, depression, Parkinson’s disease, and encephalopathy received an antipsychotic for dementia with agitation without a documented physician rationale, nonpharmacological interventions, or risk–benefit analysis as required by facility policy. Two other residents with dementia, depression, and anxiety had PRN antianxiety medications ordered without 14-day stop dates or specified durations, and their records lacked the required physician rationale for extended PRN use, despite staff acknowledging that such orders should include a 14-day limit and reassessment.
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