A resident with anorexia and dementia, and a BIMS score of 00, had a PRN lorazepam order for anxiety that was not limited to 14 days and lacked documented rationale for extension. Staff gave conflicting statements about whether the order was to be reevaluated, renewed, or extended, while the facility policy stated PRN anxiolytics are for 14 days and then reviewed by the MD.
A resident with generalized anxiety disorder and unspecified dementia was observed walking the halls and speaking incoherently to themselves. The resident had a BIMS score of 1/15, and an order for Lorazepam PRN for anxiety was written for 90 days without documented clinical rationale in the EMR. The DON stated the physician’s assessment should indicate the need for the extended duration, and the facility policy limited PRN psychotropic orders to 14 days unless the prescriber documented the reason for extension.
A resident with COPD, muscle weakness, difficulty walking, and need for assistance with personal care had orders for duloxetine for depression, trazodone for insomnia, and PRN clonazepam for insomnia/anxiety. The chart lacked documented behavior monitoring for the psychotropic meds, the cMDS did not identify an active diagnosis for the antianxiety and antidepressant meds, and the record did not clearly document an indication for insomnia. The LPN/UM confirmed behavior monitoring should be in the eMAR, and the DON stated the clonazepam order and behavior monitoring were clarified after the surveyor’s inquiry.
Inadequate monitoring and inappropriate diagnosis for antipsychotic use: A resident with severe cognitive impairment and dementia-related behaviors received quetiapine and divalproex, but the MDS did not show an active diagnosis for the antipsychotic, the care plan did not list target behaviors, and behavior monitoring was not documented when the antipsychotic was started or increased. The psych APRN described restlessness in the evenings without aggression or psychotic symptoms, while the LPN, UM, and DON stated that target behaviors and monitoring should be documented and that restlessness and agitation were not appropriate diagnoses for the antipsychotic.
Failure to follow up on a psychiatrist’s recommended GDR for quetiapine. A resident with major depressive disorder, PTSD, and paranoid schizophrenia was receiving antipsychotic medication, and the psych note recommended reducing Seroquel from 50 mg HS to 25 mg HS for 7 days, then discontinuing it. The MAR showed the medication continued as ordered, but the chart lacked documentation that the PCP or resident representative addressed the recommendation, and the consultant pharmacist also noted the need for follow-up.
A resident with dementia, hemiplegia, hemiparesis, and HTN had a PRN lorazepam order for anxiety and restlessness that was not limited to 14 days. The resident's record did not include documentation from the attending physician or prescribing practitioner with a rationale to extend the psychotropic medication, and an LPN was unsure whether the 14-day requirement applied while the SFUM stated the order should have had a stop date.
Incomplete behavior monitoring for psychotropic medication use: Two residents receiving psychotropic-related medications had behavior monitoring documentation that did not match the ordered format or did not describe the behaviors observed. One resident with dementia and schizoaffective disorder had Seroquel ordered with a requirement to document behaviors each shift, but staff entered check marks instead of yes/no responses. Another resident with dementia, schizoaffective disorder, and severe cognitive impairment had Depakote ordered, and staff documented yes on several shifts without stating what behavior occurred in the PN.
Failure to Track Target Behaviors and Monitor Antipsychotic Side Effects: The facility failed to identify targeted behaviors, track behaviors, and monitor antipsychotic side effects for two residents receiving psychotropic medications. One resident with schizophrenia received Zyprexa, and another resident with paranoid schizophrenia received Risperidone, but the MARs, notes, and physician orders did not document specific behaviors or side effects to monitor. Staff interviews confirmed they were not instructed on specific behaviors or medication side effects to observe.
A resident with anxiety and severe cognitive impairment had an active PRN alprazolam order that remained in place beyond the 14-day limit, even though it was only administered once. Another resident with dementia and psychotic symptoms had an active quetiapine order, and a psychiatrist recommended a GDR, but the EMR showed no documentation that the recommendation was addressed while the medication continued to be given as ordered. Staff, including the RN, LPN/UM, and DON, acknowledged the orders and the missing documentation.
A facility failed to complete accurate and timely AIMS monitoring for three residents receiving antipsychotic medications. One resident on olanzapine had an incomplete AIMS with no TD assessment documented and a missing later AIMS; a second resident with a history of TD had a later AIMS recorded as normal despite prior TD findings and no staff training on AIMS was identified; and a third resident on lurasidone had quarterly evaluations marked as if no antipsychotic was given, with the AIMS sections left blank.
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