A resident with depression, schizophrenia, and panic disorder received Buspirone for anxiety and Remeron for depression and insomnia, but the record contained no documented monitoring for effectiveness or side effects. The care plan called for shift-by-shift monitoring, yet the MAR and nurses' notes had no related entries. Staff interviews confirmed the psychotropic monitoring task was not properly attached and that no documentation of monitoring was found.
A resident with dementia, behavioral disturbance, and psychiatric diagnoses received a B52 injection for aggressive behavior, but the chart lacked documentation of a pre-medication assessment, identification of underlying causes, or attempts at less restrictive interventions. The record also did not show post-injection assessment or behavior monitoring, and the DON, PNP, and LPN confirmed the missing documentation and lack of documented effectiveness.
PRN psychotropic medication orders were not limited to 14 days for a resident with dementia, psychotic disturbance, disorientation, and delirium. The resident had a PRN Hydroxyzine order for anxiety related to disorientation, and the MAR showed multiple administrations. The DON confirmed the medication was psychotropic and that the PRN order was not reordered after 14 days as required.
A resident with dementia, depression, and severe cognitive impairment received PRN Ativan for target behaviors, but the order had no stop date despite the facility policy limiting PRN psychotropics to 14 days unless the practitioner documents the rationale for extension. The MAR and progress notes also lacked documentation of the behaviors supporting several Ativan administrations, and the DON confirmed no behaviors were observed or documented for those doses.
A resident with unspecified dementia, anxiety, and recurrent major depressive disorder had a BIMS score indicating moderate cognitive impairment and was receiving Abilify. The S3ADON confirmed the medication was an antipsychotic and that the resident did not have an appropriate diagnosis to support its use.
A resident with generalized anxiety and bipolar disorder had a PRN lorazepam order for anxiety and restlessness that lacked a stop date and did not include a documented rationale for use beyond 14 days. The DON confirmed the order had no stop date and no documented rationale for continued PRN use.
Unnecessary psychotropic medication use was not ensured for 3 residents. One resident with Parkinson's disease, MDD, and dementia had a Seroquel GDR recommendation that was not implemented, and three residents had PRN psychotropic orders that continued beyond 14 days without a documented rationale or stop date. The DON confirmed the missing GDR documentation and extended PRN orders.
PRN psychotropic use was not properly limited for a resident with depression, anxiety, and dementia. The resident had an order for PRN Ativan via PEG tube for agitation, but the consultant noted the order needed a prescriber review after 14 days and required documentation of the rationale and a specific duration. The record lacked that documentation, and the DON confirmed there was no documented rationale or duration for the PRN Ativan order.
Incomplete GDR for Psychotropic Medications: A resident with Parkinson's disease, Alzheimer's disease, depression, anxiety, and delusional disorder was receiving multiple psychotropic meds, including haloperidol, lorazepam, quetiapine, and sertraline. The resident's GDR did not show review of these meds for an attempted dose reduction, did not include a rationale for continuing them at the current dose, and left diagnosis fields blank for haloperidol and quetiapine; the DON acknowledged the GDR was not completed and not signed by a physician.
Delayed GDR for antipsychotic medication. A resident with anxiety disorder, depressive episodes, psychotic disturbance, and moderate cognitive impairment was receiving an antipsychotic. The pharmacist recommended reducing the nightly Seroquel dose, and the MD agreed, but there was a 2-month delay in completing the GDR process, which the DON confirmed should not have occurred.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.