Delayed Review of PRN Anxiolytic Order: A resident had an active PRN hydroxyzine order for anxiety that remained in place without a documented duration or stop date despite repeated pharmacy recommendations to re-evaluate the medication. The provider did not sign off on the recommendations for an extended period, and the MAR showed the medication stayed active while doses were administered. Staff interviews confirmed the facility expected pharmacy recommendations to be reviewed within a set timeframe, but that did not occur here.
The facility failed to ensure behavioral monitoring was in place for residents receiving psychotropic medications. A resident on Paxil for depression had no psychotropic behavioral monitoring order in the record, and two other residents receiving antidepressants, trazodone, and buspirone also had no behavioral monitoring documentation in their MARs. The DON acknowledged the lack of documentation and stated the facility did not have behavioral monitoring records for those residents.
Incomplete Documentation for PRN Compounded Psychotropic Medication: A resident with schizophrenia, MDD, aphasia, and post-CVA deficits received a PRN compounded topical psychotropic medication for agitation, but the order lacked dosage details, non-pharmacological interventions, and monitoring parameters. eMAR and nursing notes showed multiple administrations without documented nursing assessments, attempted non-pharmacological measures, or follow-up on effectiveness/adverse effects, and the NHA and DON acknowledged the documentation concerns.
A resident had a PRN Lorazepam IM order for breakthrough seizures written for 6 months without a documented seizure diagnosis, evidence of seizure activity, or clinical justification for the extended duration. The ordering provider said it was a precaution based on prior EEG findings and part of a seizure protocol, but could not identify a supporting diagnosis, and the chart showed only monitoring for seizure activity rather than seizure precautions.
A resident receiving scheduled Ativan for dementia with agitation had no evidence of a GDR attempt and no adequate clinical documentation supporting continued use. A pharmacy consultant recommended a GDR, but the MD declined it due to concern for decompensation without documenting sufficient rationale, and behavioral monitoring sheets showed no documented behaviors to justify the medication. The resident was also on Cymbalta for depression, which may address anxiety symptoms, and the DON stated the behavior logs might be inaccurate and that the resident yells out.
Psychotropic Medication Ordered Without Qualifying Diagnosis: A resident was given Seroquel for agitation, restlessness, yelling, and delusional behaviors even though the facility had not yet obtained a qualifying diagnosis. The DON said the resident was a new admission and records were still being gathered, the pharmacist identified antipsychotic use without a qualifying diagnosis, and the PNP said it was too soon to diagnose delusional disorder. The Medical Director stated the prescriber should have had a diagnosis attestation before ordering the medication.
A resident received Seroquel 75 mg HS, but the charted indication was only "psychotic symptoms," which did not identify a specific diagnosed condition to support antipsychotic use. The psych NP stated the EMR indication had been entered incorrectly.
A resident had an active PRN order for Hydroxyzine 10 mg q12h for anxiety that remained in place beyond the 14-day limit without a provider-documented rationale. The DON stated PRN psychotropic orders should be limited to 14 days unless the provider documented the extended need, and the facility policy reflected the same requirement.
A resident with LBD, Parkinson's disease, anxiety, and depression was prescribed clozapine twice daily and clonazepam at bedtime without adequate documented clinical indication. The PNP stated clonazepam should be used for schizophrenia or anxiety, but review of the attending provider's documentation and PMH showed no dx or clinical documentation of schizophrenia to support the antipsychotic and benzodiazepine regimen.
A resident receiving Mirtazapine 7.5 mg nightly had a GDR review by the psych NP, who recommended dose reduction after noting the resident was mostly asleep and unresponsive, with the roommate reporting the resident slept all the time. The recommendation was declined, but the physician note continued the medication for dementia with failure to thrive without documenting why the GDR was not attempted; the DON later stated the medication was being used to increase appetite rather than for behaviors.
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