Failure to obtain informed consent for psychotropic medications. The DON confirmed that the facility did not educate or obtain consent before giving psychotropic meds to multiple residents. One resident had antidepressants ordered without any consent in the record, another had a psychotropic consent form that did not list the meds, risks, benefits, or non-pharmacological alternatives, and a cognitively intact resident receiving Rexulti had an incomplete consent form with no signatures or dates.
Failure to document informed consent for psychotropic medications for two residents. One resident with dementia, agitation, anxiety, and depression received Risperidone and Escitalopram without consent documentation, and the DON confirmed no consent was on file. Another resident had orders for Pregabalin, Hydroxyzine, Donepezil, and Fluoxetine, but the record contained no informed consent for psychotropic meds, and the Regional Corporate Nurse confirmed the lack of documentation.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Alternatives: Surveyors found that the DON confirmed residents receiving psychotropic meds were not given signed forms or advance discussion of risks, benefits, and alternatives before administration. Records for several residents with diagnoses such as dementia, depression, schizoaffective disorder, bipolar disorder, Alzheimer’s disease, and Down syndrome showed orders for antipsychotics and antidepressants, but no evidence that the resident and/or representative was informed in advance of care.
A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had orders for clonazepam PRN and lamotrigine at HS, but the EMR contained no evidence of informed consent or documentation that benefits and side effects were explained for either psychotropic medication. The ADON confirmed the missing consent in the resident's record.
Surveyors found that the facility did not ensure residents and their POAs were informed of the risks, benefits, side effects, and alternative/non-pharmacological options before initiating or continuing antipsychotic and other psychotropic medications, and did not notify a POA of new skin conditions. Several residents with diagnoses including delusional disorder, anxiety, bipolar disorder, dementia, and major depressive disorder were receiving medications such as Risperidone, Depakote, Risperdal, Xanax, Mirtazapine, Olanzapine, and a compounded topical Ativan/Benadryl/Haldol preparation. Facility policy required education on psychotropic drug use, but medical records and care plan notes lacked specific documentation of risk/benefit and alternative treatment education, and the DON acknowledged that POAs were not informed prior to prescriptions being written and dispensed. In addition, one resident developed multiple new foot and heel wounds, yet the POA reported being unaware of any skin issues, and an LPN confirmed there was no communication to the POA about these wounds or related interventions.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not document informed consent or provide information on benefits, risks, side effects, or alternative treatment options for psychotropic meds for several residents. A resident with quadriplegia and mood disorder was on Celexa, a resident with vascular dementia and hallucinations had PRN Lorazepam, and two residents with dementia, anxiety, depression, or agitation received Seroquel, including one with a dose increase, but the EMR lacked consent documentation. The DON and RN-O confirmed the missing documentation.
Failure to Obtain Consent Before Psychoactive Medications: The facility did not document that residents and/or their representatives were informed of the risks and benefits and gave consent before psychoactive meds were started or increased for 3 residents. One resident with anxiety and insomnia received Buspirone and Zolpidem without documented consent, another resident with bipolar disorder and PTSD received Vraylar and Amitriptyline increases without prior consent documentation, and a third resident with schizophrenia-related diagnoses received Fluvoxamine without documented consent. The DON confirmed the missing consent documentation.
The facility failed to obtain documented consent and fully inform two residents or their representatives before administering psychotropic medications. One resident received Rexulti and Trintellix without consent or documentation of risks, benefits, or alternatives, and another resident’s psychotropic consent form for Zoloft and Alprazolam was incomplete, with no symptoms or nonpharmacological alternatives documented and no education provided.
Incomplete informed consent for psychotropic medications. Two residents had psychotropic drug orders documented on the MAR and MDS, including an antidepressant, antipsychotic, mood stabilizer, and antianxiety medication, but the consent forms did not include required side effects, and one resident’s consent also listed incorrect meds and dosages. The DON confirmed the consent forms were incomplete and that a new consent should have been completed when psychotropic orders were added or increased.
Late or Missing Informed Consent for Psychotropic Medications: The facility failed to obtain informed consent in advance for psychotropic meds for four residents. Records showed residents with dementia, depression, anxiety, bipolar disorder, and behavior issues received antidepressant, antianxiety, and antipsychotic meds before consent was signed, and one resident had no consent on file for a psychotropic med. The MDS Coordinator confirmed the consents were obtained after the meds had already been started or were missing.
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