The facility failed to complete GDRs for psychotropic meds, failed to obtain a physician response to pharmacist GDR recommendations, and used an antipsychotic without an appropriate diagnosis for a resident. One resident with dementia, depression, and anxiety had orders for buspirone, duloxetine, and Rexulti, but the GDR request was sent to psychiatry with no documented response. Another resident with anxiety and amnesia had pharmacist recommendations to reduce buspirone or mirtazapine with no documented physician response or GDR, and a third resident had aripiprazole, buspirone, and mirtazapine ordered for altered mental status, which the consultant pharmacist said was too vague a diagnosis.
The facility failed to limit PRN psychotropic medication orders to 14 days for two residents and failed to document appropriate diagnoses for psychotropic use for two other residents. One resident had buspirone ordered for Alzheimer's disease without an appropriate diagnosis, and another had Zyprexa ordered for agitation and sundowning, which the DON, Medical Director, and Administrator said were not acceptable diagnoses. Two residents also had lorazepam PRN orders without stop dates.
Psychotropic medication management was deficient for multiple residents. One resident had aripiprazole ordered for dementia without an appropriate diagnosis, another resident had several psychotropic medications with no documented pharmacy recommendation for an appropriate diagnosis for trazodone and no documented GDRs for multiple meds, and a third resident had mirtazapine without an appropriate diagnosis plus a PRN lorazepam order with no stop date. Staff interviews confirmed the resident had not had recent behaviors, and the DON and Administrator stated psychotropic meds should have an appropriate diagnosis and PRN orders should have a 14-day stop date.
Two residents received antipsychotic meds without documented appropriate diagnoses, and one resident also had no documented GDR attempt. One resident was on Zyprexa for dementia-related behaviors despite records showing severe cognitive impairment and no hallucinations, delusions, behaviors, or rejection of care, while another resident was on quetiapine for anxiety and sleep disorder with no documentation supporting the diagnosis or a GDR attempt. The DON and Admin stated they would expect correct diagnoses and attempted GDRs when appropriate.
The facility failed to have an appropriate diagnosis for one resident's antipsychotic order and failed to limit another resident's PRN antipsychotic order to 14 days. One resident received quetiapine for depression despite diagnoses including Parkinson's disease with dyskinesia, and another resident had haloperidol PRN for hallucinations with no stop date. The DON, Administrator, and MD stated psychotropic meds should have an appropriate diagnosis and PRN antipsychotics should have a 14-day stop date.
A resident with dementia and a history of stroke was admitted without psychotropic medications and initially assessed as alert and pleasant, yet staff quickly obtained and administered IM haloperidol for attempts to ambulate without assistance, followed by multiple PRN and scheduled orders for risperidone, lorazepam, Zoloft, and Seroquel for behaviors such as anxiety, yelling, roaming, and standing up from a wheelchair. The facility did not complete a comprehensive assessment or develop a care plan addressing antipsychotic use, and nursing documentation frequently lacked detailed descriptions of behaviors, nonpharmacological interventions, or behavior monitoring at the time medications were given. Interviews with an RN, DON, NP, physician, and the Administrator confirmed that the indications and dosing for antipsychotics, including high-dose risperidone and IM haloperidol, were not appropriate for the behaviors described and that nonpharmacological approaches should have been attempted first, contrary to facility policy requiring residents to be free from chemical restraints and mandating thorough, interdisciplinary care planning.
The facility failed to monitor PRN psychotropic meds for two residents by allowing open-ended orders for Haldol and alprazolam to continue without the required 14-day limit or documented provider rationale. One resident with impaired cognition, anxiety, malnutrition, and hospice care received PRN Haldol multiple times, and another resident with stroke, dementia, anxiety, depression, and hospice care received repeated PRN alprazolam doses. The record showed no pharmacy recommendation and no physician documentation supporting continued use.
A resident with anxiety and depression had a PRN lorazepam order without the required 14-day stop date, and another resident receiving aripiprazole had no documented diagnosis supporting the antipsychotic use. The DON and Administrator acknowledged that PRN psychotropics should have a 14-day stop date and that all medications should have an appropriate diagnosis.
A resident with dementia and agitation was receiving multiple psychotropic medications, including scheduled antianxiety, antidepressant, antipsychotic, and anticonvulsant drugs. Staff documented repeated episodes of pacing, wandering, aggression, sexual inappropriateness, and restlessness, but progress notes did not show detailed behaviors, triggers, or non-pharmacological interventions before PRN lorazepam was given. The care plans were general and did not include comprehensive target behaviors or individualized interventions, and the PRN lorazepam order lacked a stop date.
The facility failed to limit PRN psychotropic medication orders to 14 days for one resident and failed to ensure an appropriate diagnosis supported Seroquel use for another resident. One resident with dementia with psychotic disturbance remained on Seroquel without documentation addressing the black box warning, diagnosis, or behaviors, while another resident on hospice had a PRN lorazepam order for anxiety/terminal restlessness without a 14-day stop date. The DON acknowledged PRN psychotropics should have a 14-day stop date, and the Administrator stated policy should be followed.
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