Psychotropic Medication Indications and Monitoring Not Properly Documented: Surveyors found that two residents had psychotropic medications ordered without appropriate documented indications, and two residents were not monitored for side effects. One resident with dementia, psychosis, and severe cognitive impairment had Seroquel and Depakote orders, but no adverse-effect monitoring was documented. Another resident with dementia, psychosis, depression, and CKD V had quetiapine orders, but side-effect monitoring was absent and AIMS testing was not completed per policy. A third resident with Alzheimer’s disease and dementia with agitation had olanzapine and risperidone orders with indications the DON confirmed were not appropriate.
Two residents received PRN psychotropic medications without documented evidence of the reason for use or attempted non-pharmacological interventions before administration. One resident with dementia-related behavioral issues received lorazepam and hydroxyzine multiple times, but staff did not document the behaviors or interventions in the MAR, progress notes, behavior book, or 24-hour reports at the time of administration. Another resident with dementia, delusional disorder, and anxiety received Vistaril several times, and the progress notes did not show non-drug measures were tried first; the care plan also lacked individualized non-pharmacological interventions.
Lack of Monitoring for Psychotropic Medications: The facility failed to document monitoring for effectiveness and adverse effects for multiple residents receiving psychotropic meds. Residents with diagnoses including dementia, psychotic disturbance, anxiety, depression, COPD, and other conditions received medications such as mirtazapine, olanzapine, buspirone, sertraline, cariprazine, ziprasidone, and lurasidone, but the MAR/TAR and progress notes showed no documented monitoring, despite care plans calling for staff to monitor and report adverse effects.
A resident with dementia, depression, psychosis, and severely impaired cognition received multiple PRN doses of lorazepam for anxiety/restlessness, but the record showed no documented non-pharmacological interventions before those administrations. The care plan directed staff to use PRN psychoactive meds only after non-drug measures were ineffective, and the DON confirmed no such interventions were provided before the doses reviewed.
Inadequate Monitoring for Psychotropic Medication Adverse Effects: A resident with morbid obesity, type II DM, and a left femur fracture received buspirone for anxiety and duloxetine for depression, with orders for behavior and adverse effect monitoring. The MAR showed the meds were administered as ordered, but the adverse effect monitoring order was discontinued and there was no current monitoring order despite the resident being cognitively intact and having no documented behaviors or adverse reactions.
Unjustified Psychotropic Medication Use: A resident with Parkinson's disease, dementia, anxiety, depression, and other diagnoses was prescribed Quetiapine and Depakote for delusions, paranoia, psychotic disorder, and dementia-related mood disturbance without documentation supporting a psychotic disorder diagnosis. Psychiatry notes did not document psychotic disorder, behavioral logs showed little documented behavior, and the DON confirmed there was no diagnosis supporting the antipsychotic use.
Unnecessary antipsychotic use without CMS-supported indication. A resident with moderate cognitive impairment and multiple chronic diagnoses was receiving Lurasidone 20 mg daily despite a psychiatric note stating the medication lacked a CMS-supported indication and was without an appropriate diagnosis per CMS guidelines. An RN confirmed the resident was still on the medication and acknowledged it was not recognized as appropriate per CMS guidelines, while citing a mood disorder documented by another provider as the basis for use.
A resident with anxiety disorder and other psychiatric and pain-related diagnoses received PRN Ativan beyond the 14-day limit for psychotropic meds. The order did not include a stop date, and MAR review showed the medication was given for 23 total days before it was discontinued; the DON confirmed the missing 14-day stop date.
Inadequate indication for antipsychotic use: A resident who was cognitively intact and had no mood, psychosis, or behavioral symptoms was given Abilify 20 mg daily for mood/anxiety/depression without an approved diagnosis. The MAR showed daily administration with no documented behaviors, and an RN confirmed the resident lacked an approved indication for the antipsychotic.
Antipsychotic Used Without Timely Supporting Diagnosis: A resident with severe cognitive impairment and dementia received Risperdal 0.5 mg BID for agitation without an appropriate diagnosis documented to support its use. The MRR identified the missing diagnosis, but the physician did not address the irregularity in a timely manner, and the DON confirmed the delay.
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