The facility failed to ensure physician review of pharmacy GDR recommendations and failed to include stop dates on PRN psychotropic orders for several residents. A resident had PRN Klonopin without a stop date, two PRN lorazepam orders also lacked stop dates, and pharmacy recommendations for dose reduction of psychotropics for two cognitively intact residents remained unaddressed. The DON confirmed the unaddressed recommendations and missing stop dates.
A resident with dementia and moderately impaired cognition was receiving quetiapine for hallucinations and sertraline for depression, but the facility did not attempt or document a GDR for the psychotropic medications. The MDS noted no GDR had been documented as clinically contraindicated, and interviews with the DON, pharmacy consultant, NP, attending physician, and Administrator confirmed the GDR was missed.
A resident with dementia and severely impaired cognition had active PRN orders for Lorazepam and Diazepam that were entered without required 14-day stop dates, contrary to facility policy and federal requirements. Policy required all PRN psychotropic medications to be limited to a 14-day duration unless a physician documented clinical rationale and specified a longer duration. Review of records and a pharmacy consultant report showed the PRN psychotropic orders remained active beyond 14 days without documented physician justification or renewal. The DON, Administrator, and pharmacy consultant each confirmed that these PRN psychotropic orders should have been time-limited and either discontinued or renewed with appropriate documentation.
Failure to Reassess PRN Psychotropic Medication: A resident with Alzheimer's disease and severe cognitive impairment remained on a PRN lorazepam order for anxiety beyond the 14-day limit without documented physician reassessment. The facility policy limited PRN psychotropic use to 14 days unless the physician documented a rationale to extend it, and the DON acknowledged awareness of the requirement but did not ensure the medication was reevaluated. Staff also reported the resident was on hospice, had increased behaviors after Seroquel was discontinued, and lorazepam had been increased for agitation.
A resident with severely impaired cognition and diagnoses including brain degeneration and persistent mood disorder received a PRN Ativan order for air hunger or anxiety that did not include a specified duration or evidence of 14-day re-evaluation. The resident was also receiving antipsychotic, antianxiety, and antidepressant medications. An LPN reported the resident was receiving Ativan and Morphine, while the DON and NP stated they believed the 14-day PRN requirement did not apply to hospice residents.
A resident with dementia and insomnia had a pharmacy-recommended GDR for trazodone changed to 50 mg PRN, and the physician signed to implement it as written. However, the DON confirmed the order was never updated in the computer, and the resident continued receiving trazodone 50 mg every evening instead of only as needed.
A resident with severe cognitive impairment and dementia was administered Haldol and Sertraline without documented consent from their representative, despite facility policy requiring informed consent for psychotropic medications. The DON confirmed that no consent forms were found, and the representative was unaware of the medications until after requesting a list.
A resident received Geodon without an appropriate approved diagnosis and without documented informed consent. Staff and the NP stated the medication was intended for psychosis-related behaviors, but the resident did not have bipolar disorder or schizophrenia, and the DON confirmed psychosis was not an approved indication. The resident was repeatedly observed asleep in her wheelchair, often slept through meals and med passes, had no documented behaviors in the behavior log, and experienced significant meal refusals and major weight loss.
A resident on hospice with anxiety and moderate cognitive impairment received a PRN Lorazepam order with no stop date beyond the 14-day limit for psychotropic medications, and the record lacked the required provider documentation for extending therapy. The eMAR showed repeated administrations over multiple days, with behaviors documented only once, and the consultant pharmacist recommended discontinuation or documentation of the indication, intended duration, and rationale for continuation; the recommendation was declined due to hospice status without a provider signature or date.
A resident was prescribed multiple antipsychotic medications, including Olanzapine and Haloperidol, for indications such as mood and psychosis, despite medical records only documenting depression and no other psychiatric or mood disorders. Staff interviews revealed that the pharmacist and nursing staff relied on general processes for associating diagnoses with medication orders, but the documentation did not support the clinical need for these antipsychotic prescriptions.
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