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.
A resident with dementia remained on Risperidone 1 mg BID without a GDR being attempted, despite repeated NP recommendations to reduce the dose. The NP documented that the reason for the antipsychotic was unclear and that the resident was stable with no hallucinations or delusions noted. Staff interviews showed the recommendation was not communicated or followed through with the physician, and the physician stated he was not aware of the behavioral health recommendations.
Unnecessary PRN Psychotropic Medication: A cognitively intact resident with anxiety disorder and major depressive disorder was ordered alprazolam 0.5 mg PO q8h PRN for anxiety and received it 51 times on the MAR review. The record did not show a required 14-day stop date for the PRN psychotropic, and the DON and an RN stated that PRN psychotropics require a stop date and physician re-evaluation if continued.
PRN Haldol Was Continued Without Required Reassessment: A resident with dementia and parkinsonism had a PRN Haldol order for agitation that stayed active beyond the 14-day limit. The MAR showed multiple PRN doses were given, but NP notes did not address the medication, and the UM and DON stated the order required provider reevaluation and a face-to-face visit for continued use.
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