Failure to Complete Ordered Clozaril Monitoring: A resident with dementia, psychotic disturbance, and severe cognitive impairment received scheduled Clozaril, but the facility did not ensure ordered 6-month lab monitoring was completed and resulted. The record showed a prior elevated Clozaril level during a hospitalization for altered mental status, yet the later lab result was unavailable and staff could not identify why the monitoring was not followed through.
A resident with anxiety, Alzheimer’s disease, and dementia with mood disturbance received PRN Trazodone for agitation, but the order lacked a duration of use and the prescriber did not document ongoing reassessment or a clinical rationale for continued use. The record showed repeated administrations of the medication, while nursing and provider notes did not show the required follow-up reviews after the initial continuation order.
A resident with PTSD, anxiety, major depressive disorder, and intact cognition remained on daily Aripiprazole even after the psych NP recommended a GDR to every other day for 1 week, then discontinue. Nursing did not communicate the recommendation to the physician, the MAR showed the medication continued as ordered, and interviews confirmed the physician was unaware of the GDR while the DON stated the psych recommendation was missed by nursing.
A resident with anxiety disorder, alcoholic liver disease, and CKD stage 4 was receiving psychotropic meds, including sertraline and trazodone, despite the record lacking signed informed consent from the resident or representative before administration. The resident was cognitively intact with a BIMS of 15, and the MAR showed both meds were given as ordered over several months. A nurse and the DON stated consent should be obtained before new psychotropic meds are administered, but no signed consent could be found.
A resident with dementia, psychotic disturbance, anxiety, depression, and severe cognitive impairment received PRN quetiapine for agitation without the required physician assessment and documented rationale for continued use. Pharmacy and psych notes stated the PRN antipsychotic should be discontinued or reassessed, but the order remained in place and was administered multiple times without the required review.
PRN olanzapine remained active beyond the 14-day limit for a resident with depression, vascular dementia, and Alzheimer's dementia. The resident had severe cognitive impairment and was receiving antidepressant and antipsychotic medications, but the PRN antipsychotic order stayed in place for 57 days and was administered four times after the initial 14 days without documented provider review or extension at each interval. Staff and the DON confirmed the order should have been limited to 14 days.
Two residents had PRN trazodone orders without required stop dates. One resident with depression and moderate cognitive impairment had trazodone ordered PRN for insomnia, and another resident with Alzheimer's disease, depression, and severe cognitive impairment had trazodone ordered PRN for agitation and received it multiple times. Facility policy and staff interviews confirmed PRN psychotropic meds require a 14-day stop date and documentation for any extension.
PRN Psychotropic Medications Lacked Required Reassessment: Two residents received PRN benzodiazepine orders without the required provider reevaluation after the initial 14-day period. One resident had intact cognition and was ordered Ativan PRN, while another resident with dementia and anxiety had a PRN Lorazepam order without a stop date. Staff, including an RN, the UM, and the DON, stated PRN psychotropic meds require a stop date and provider review.
Failure to Document GDRs for Psychotropic Medications: Two residents with psychiatric diagnoses and intact cognition were receiving multiple psychotropic meds, including antipsychotic, antidepressant, antianxiety, and mood-stabilizing agents. MD and NP notes repeatedly stated moods and behaviors were stable and current meds should continue, but the record did not show a GDR attempt or a documented clinical contraindication for either resident. The DON stated she could not find such documentation in the medical record.
Unnecessary PRN Ativan Use Without Required Documentation: A resident with anxiety disorder and severe cognitive impairment had PRN Ativan orders extended beyond the 14-day limit without the required physician or extender documentation of a clinical rationale. The record showed multiple PRN Ativan orders for anxiety/agitation, including an order extension noted in a physician progress note, but the chart did not contain documentation of an evaluation or rationale for continued use, which the Unit Manager and DON both confirmed during interview.
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