Failure to document informed consent for psychotropic medications: The facility did not provide documentation that residents and/or their responsible parties were informed of the risks and benefits before psychotropic medications were started for nine residents. The affected residents had diagnoses including MDD, anxiety, bipolar disorder, dementia, PTSD, suicidal ideations, and malnutrition, and were prescribed medications such as antipsychotics, antidepressants, antianxiety agents, and lamotrigine without documented consent or education. The DON and Administrator stated they would expect residents to be informed of the risks and benefits of psychotropic medications.
Failure to inform residents of risks and benefits before psychotropic medications were started. The facility had no documentation of consent or education for multiple residents receiving antipsychotics, antidepressants, antiseizure medications used as mood stabilizers, and antianxiety medications. Residents had diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, dementia, depression, anxiety, PTSD, and other behavioral or neurologic conditions. One resident said he/she did not recall staff explaining the risks and benefits, and an LPN and the DON said they expected residents and/or representatives to be informed.
Failure to Obtain Written Consent for Psychotropic Medications: The facility did not document written consent before starting psychotropic meds for four residents. Records showed no informed consent for antipsychotic, antidepressant, or anticonvulsant use for residents with diagnoses including dementia, stroke, depression, psychotic disorder, and impaired cognition. The DON and Administrator acknowledged that written consents should have been in the medical record.
The facility failed to document that two residents were informed of the risks and benefits of prescribed psychotropic medications before use. One resident with anxiety and depression had an order for buspirone, and another resident with bipolar disorder had orders for buspirone, quetiapine, and sertraline, but the record lacked consent or documentation that the resident or representative was informed. Facility leadership stated residents and/or representatives should be informed in advance of risks, benefits, and treatment alternatives.
Failure to Obtain Informed Consent for Psychotropic Medications: Multiple residents with diagnoses including dementia, anxiety, depression, bipolar disorder, schizoaffective disorder, and Alzheimer's disease had orders for psychotropic medications such as antipsychotics, antidepressants, mood stabilizers, and anxiolytics, but their records lacked documentation of consent or education about risks and benefits. The CCO stated psychotropic medication consent forms had been discussed but not yet initiated, and the DON said residents or their representatives would be expected to receive informed consents.
Failure to obtain written consent before starting psychotropic medications for three residents. One resident had intact cognition and was receiving diazepam and quetiapine, while two others had impaired cognition and were receiving antianxiety, antipsychotic, and antidepressant medications. Records showed no signed consents before or after the meds were started, and interviews confirmed the DPOA had not been asked to sign paperwork and staff were unsure who was responsible for obtaining psychotropic consent.
Failure to obtain and document informed consent for psychotropic meds affected three residents. One resident with spinal cord injury, quadriplegia, PTSD, and major depressive disorder had Seroquel ordered for PTSD; another resident with schizophrenia had Risperdal ordered; and a third resident had Seroquel ordered twice daily. Records lacked documentation of consent or education on risks and benefits, and the residents and a spouse did not recall reviewing medication risks, benefits, side effects, or other treatment options with staff.
Failure to obtain informed consent before starting psychotropic medications affected three residents. One resident with impaired cognition, depression, and a CVA history started antidepressants before consent was signed, while another resident with severe cognitive impairment and dementia had incomplete consent forms for an antipsychotic and an anxiolytic that were not properly signed or dated. A third resident with severe cognitive impairment, dementia, depression, psychotic disorder, and anxiety had psychotropic consent forms that were not signed by the legal guardian and were otherwise incomplete.
Failure to obtain written consent for psychotropic medications for two residents. One resident had anxiety, depression, schizophrenia, and non-Alzheimer’s dementia, and the other had depression, schizophrenia, and traumatic brain injury with communication problems and dependence on staff for care. Records showed psychotropic orders including antipsychotic and antidepressant medications, but no consent forms were on file. An LPN was unsure about consent requirements, and the DON and Administrator stated they had interpreted the policy incorrectly.
Failure to Obtain Consent Before Starting Psychotropic Medications: The facility did not obtain consent from residents or their representatives before starting psychotropic medications for four residents. Records showed antidepressant, anti-anxiety, and other related meds were initiated before consent was documented, and facility leaders stated nursing, social services, or administration were responsible for obtaining consent before these meds were started.
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