A resident with major depressive disorder, Parkinson’s disease, and severe cognitive impairment remained on quetiapine 100 mg BID even after psychiatry recommended lowering Seroquel to 25 mg BID for one week and then stopping it. The consult was misfiled in the EMR, so the primary provider did not see it, and the GDR was not implemented for over a month. Progress notes continued to list Seroquel, Remeron, ropinirole, supportive care, and psychiatry follow-up, while staff later stated the missed consult explained why the dose reduction was delayed.
Unnecessary psychotropic medication use was identified for multiple residents. Two residents had PRN lorazepam orders that exceeded the 14-day limit, one resident on aripiprazole had no documented GDR attempt or clinical contraindication, and another resident had an antipsychotic without an appropriate dx. The facility policy required PRN psychotropics to be limited to 14 days and annual GDR attempts unless clinically contraindicated.
A resident with dementia and depression received Seroquel and later Trazodone without adequate documentation of target behaviors, diagnostic justification, or monitoring for effectiveness and side effects. The MDS showed severe cognitive impairment, no psychosis, and no behavioral symptoms, yet antipsychotic therapy continued without a documented GDR attempt or physician rationale for contraindication. Care plans for behavior, dementia, and psychoactive meds required behavior tracking and evaluation of interventions, but monitoring notes were essentially absent. Psychiatric consults referenced major depressive disorder and dementia without behavioral disturbance and instructed staff to document mood and behavior, but the facility record did not contain behavior data to support reported aggression or poor sleep. CNAs and an LPN reported only occasional shower refusal and mild agitation, while the family stated they had not seen aggressive behavior, questioned the bipolar diagnosis, and said they were not informed about initiation of psychotropic meds. Leadership interviews acknowledged incorrect indications on orders and poor behavior documentation, yet the resident continued on psychotropics without the required supporting documentation.
PRN psychotropic medication order lacked required end date. A resident with schizophrenia, CKD, and iron deficiency anemia had a lorazepam order for anxiety without an end date, despite facility policy limiting PRN psychotropic orders to 14 days. The DON stated nurses should recognize the end-date requirement and correct pending orders, and the MD stated they relied on nurses to cue needed order changes.
A resident with dementia, TBI, and severely impaired cognition was started on Buspirone for reported agitation without documented evidence that nonpharmacologic measures were tried or that underlying medical causes were ruled out. The dose was later increased to help the resident comply with a hospital transfer, then continued after the resident was treated for a UTI and was no longer showing the behaviors that prompted the change. Records also showed no documented psychiatry re-evaluation after the last follow-up and no clear reassessment of the ongoing need for the antianxiety medication.
A resident with dementia, anxiety, and a history of hallucinations and paranoid delusions was receiving Buspirone, Seroquel, and opioid pain medications, and was repeatedly observed appearing lethargic or asleep during the day. Survey review found no clear evidence that a GDR was completed despite long-term Seroquel use, conflicting documentation about behavior monitoring and dose reduction attempts, and provider notes stating the resident was stable and not appropriate for GDR while the dose remained in place.
A resident with dementia, anxiety, and major depression received an increased Xanax dose without documented clinical indication. The chart showed the dose changed from 0.25 mg to 0.5 mg every 8 hours, while the psychiatry PA and NP documented continuation of the lower dose and no need for an increase. BMARC notes also lacked support for the higher dose, and staff interviews confirmed the order was transcribed incorrectly and that the resident had no behaviors or increased anxiety documented.
A resident with schizophrenia and anxiety disorder received an antipsychotic at a higher dose than intended after an EMR conversion. The psychiatrist and MD had lowered the olanzapine dose, but the old order was carried into the new EMR as the higher dose and the MAR showed the resident continued receiving it. The pharmacy EMR specialist, MD, administrator, and LPN all stated the lower dose was not properly verified during the transfer.
PRN Ativan for a resident with dementia and severe cognitive impairment was left active without an end date and was not reassessed or limited to 14 days as required for psychotropics. The MAR showed the order remained in place across multiple months, the resident did not receive PRN doses, and there were no provider progress notes or documented renewals showing review of the PRN use. Pharmacy reviews flagged the issue, and staff interviews confirmed the order should have been reviewed and reordered every 14 days.
A resident with Parkinsonism, anxiety, and depression was physically restrained by multiple staff members and administered an intramuscular antipsychotic after refusing oral medication, despite no documented medical symptom or assessment justifying the use of a chemical restraint. The facility's policy prohibits such restraints, and care plans did not document specific non-pharmacological interventions prior to the incident.
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