Failure to obtain psychotropic medication consent: The facility did not document written informed consent for psychotropic medications for three residents. One resident had Alzheimer’s disease, anxiety, and bipolar disorder and was receiving lorazepam and sertraline; another was cognitively intact and receiving multiple psychotropics including lorazepam, buspirone, venlafaxine, lithium, mirtazapine, and quetiapine; and a third cognitively intact resident was receiving alprazolam twice daily, but the consent form was unsigned and undated. The DON stated the consents had not all been completed and signed.
A resident with severe cognitive impairment, dementia, schizophrenia, and stage four lung cancer had hospice and code status decisions documented without a legally authorized representative. The Administrator signed the hospice consent and DNR request, while the resident's record also showed a full code preference and a physician deposition stating a guardian should be appointed. Staff interviews indicated the resident lacked family involvement, guardianship was not completed, and the resident was not able to participate meaningfully in the consent process.
Failure to inform residents or their representatives in advance of the risks, benefits, and alternatives of psychotropic medications. Two residents had psychotropic medications started without documentation that informed consent was provided before initiation, including an antipsychotic for a resident with dementia and agitation and multiple psychotropics for a resident with dementia, bipolar disorder, and anxiety. The DON said consents were charted in progress notes, while an LPN said the psychiatry provider verbally discussed the medications and documented the conversation.
The facility failed to inform residents and/or their representatives of the risks and benefits before starting psychotropic meds for four residents. Records showed residents with diagnoses such as schizoaffective disorder, bipolar disorder, dementia with behavioral disturbances, anxiety, and depression were receiving antipsychotic, antidepressant, antianxiety, and mood-stabilizing meds, but the charts lacked psychotropic consents and documentation of education for several ordered medications. Staff interviews showed RN A believed consents were only needed for new meds started in the facility or dose changes, and the DON said the facility had not been completing psychotropic medication consents for all residents receiving them.
Failure to obtain informed consent for psychotropic medications: The facility did not document that residents and/or their representatives were informed in advance of the risks, benefits, and alternatives before psychotropic medications were started for multiple residents. Records showed missing or incomplete consents for medications such as buspirone, antidepressants, antipsychotics, and lorazepam in residents with diagnoses including dementia, anxiety, depression, psychotic disorder, Parkinson’s disease, COPD, and atrial fibrillation. Staff interviews showed confusion about psychotropic evaluations versus consents, and the QA Nurse reported that some consents were completed, some were incorrect, and some were not completed.
Failure to obtain informed consent for psychotropic medications: Five residents with diagnoses including dementia, MDD, anxiety, and behavioral symptoms were started on multiple psychotropic medications, including antipsychotics, antidepressants, benzodiazepines, and other mood-related drugs, but the record lacked documentation that the residents and/or their representatives were informed in advance of the risks and benefits. An LPN stated psychotropic consents were known but not thought to be done at the facility, and the DON and Administrator said they expected informed consent to be obtained.
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.
Resident Not Fully Informed About Xanax Risks and Benefits: A cognitively intact resident with anxiety was ordered Xanax 0.5 mg TID, but the EHR showed no evidence the resident was informed of the medication's risks and benefits. The resident did not recall anyone explaining the medication or obtaining consent, and the care plan lacked goals or interventions for psychotropic use. An LPN and the DON both stated a consent form and care plan should have been in place.
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.
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 August 26, 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.