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.
A resident received Risperdal with inconsistent documentation supporting schizophrenia or psychosis, and the chart showed frequent changes in dose and indication without proper assessment or timely documentation. MDS coding, psych notes, and provider entries conflicted over whether schizophrenia was present, while the DON validated the lack of proper documentation for the antipsychotic regimen.
A facility failed to ensure psychotropic meds were used appropriately for multiple residents. One resident with dementia-related psychosis had a PRN psychotropic order with no 14-day limit and no documentation of why it was given or that nonpharmacologic interventions were tried. Another resident also had a PRN psychotropic order with an indefinite end date. A third resident received Depakote for mood swings and melatonin for insomnia, but the chart lacked documented side effect monitoring, GDR attempts, or clinical justification despite repeated med regimen reviews stating no recommendations.
Psychotropic medication monitoring and PRN evaluation deficiencies were identified for two residents. One resident receiving duloxetine for depression did not have a behavior monitoring order, despite the DON stating psych meds require behavior monitoring. Another resident with anxiety received scheduled lorazepam plus repeated PRN lorazepam orders, but the record lacked documentation of provider or psychiatry evaluation before the PRN orders, and one nurse-entered PRN order was not verified by a provider until several days later.
A resident with schizoaffective disorder was receiving an antipsychotic routinely and PRN, but the PRN order did not include a stop date or 14-day limit. The DON stated the facility’s process for PRN psychotropic medications was to limit use to 14 days, and the facility policy also required PRN psychotropic medications to be limited to 14 days.
Failure to Monitor Residents Receiving Psychotropic Medications: The facility failed to ensure adequate monitoring for three residents receiving psychotropic medications, including orders for anxiolytic, antidepressant, antipsychotic, and sedative medications. Their records lacked behavior monitoring, side effect monitoring, and non-pharmacological intervention orders, and the ADON confirmed these monitoring measures had not been initiated when documentation was requested.
A resident was administered quetiapine and PRN lorazepam for behavioral symptoms without proper documentation of behavior monitoring, nonpharmacological interventions, or attempts at gradual dose reduction. The PRN psychotropic order lacked a required 14-day stop date, and the consent for psychotropic use was signed on admission without evidence of exhausted nonpharmacological approaches. Staff interviews confirmed inadequate documentation and inappropriate diagnoses for medication use.
The facility failed to adequately monitor a resident receiving daily antianxiety medication for anxiety. Although the care plan directed staff to monitor and record medication effectiveness, side effects, adverse consequences, and behaviors, the MAR and TAR lacked documentation showing that staff monitored the resident’s behaviors or side effects related to the psychotropic medication. The RN stated behaviors and side effects were documented for all residents, but the DON reviewed the record and confirmed the documentation was missing.
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 June 24, 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.