Chemical restraint used to stop elopement behavior and PRN Ativan order left active beyond 14 days. An LPN and CMA blocked a resident with severe cognitive impairment and Alzheimer’s disease, seated the resident in the dining room, and attempted to administer PRN morphine after the resident was trying to elope and repeatedly refused the medication. Staff interviews and video showed the resident resisting and stating the medication was poison. The facility also kept a PRN Ativan order active for another resident with dementia and anxiety beyond the 14-day limit, and the MAR showed multiple administrations while the DON stated there was no documentation the pharmacy notified the physician.
A resident with anxiety disorder and intact cognition had an active PRN Xanax order for anxiety with no end date listed. Facility policy required PRN anxiolytics, including Xanax, to have an initial 14-day stop date, and the NP, MD, and DON all confirmed the order should have included a stop date.
Unnecessary psychotropic use without adequate indication or GDR. A resident with severe vascular dementia, depression, and anxiety received Invega Sustenna for psychotic disturbances despite charted notes showing no hallucinations or delusions and no documented schizophrenia assessment before the diagnosis appeared in the record. A pharmacist requested a GDR, but it was not completed, and the dose was later increased even though the resident’s mood was stable and staff described only occasional behaviors tied to discomfort or unmet needs.
PRN Psychotropic Medication Used Beyond 14 Days: A resident with depression and a seizure disorder was prescribed lorazepam PRN for anxiety, restlessness, and/or agitation with no end date. The MAR showed the medication was administered on multiple occasions, and the DON stated the psychotropic should have been limited to 14 days with a stop date and new order obtained.
A resident with moderate cognitive impairment was receiving a daily antidepressant (fluoxetine 10 mg) under a physician’s order, and the care plan directed staff to monitor and document medication side effects and effectiveness. Facility policy required proactive monitoring and documentation of side effects for all medications, including psychotropics. However, review of the treatment administration record over several months showed no documentation of side effect monitoring for this resident, and the DON confirmed that no such monitoring had occurred, despite many residents in the facility receiving psychotropic medications.
Inappropriate Diagnoses for Antipsychotic Use: The facility failed to ensure appropriate diagnoses for antipsychotic use for two residents. One resident received Seroquel for anxiety despite being cognitively intact, and the DON and pharmacy consultant stated anxiety was not an acceptable diagnosis for antipsychotic use. Another resident received Seroquel for dementia without behavioral, psychotic, or mood disturbances, and the DON stated dementia was not an appropriate diagnosis for antipsychotic use.
A resident received quetiapine for vascular dementia with agitation despite a facility policy that did not permit antipsychotic use for any form of dementia. Physician orders directed scheduled morning and bedtime doses, and the MAR showed the medication was administered on multiple consecutive days. The DON confirmed antipsychotics were not approved under the policy for dementia, while an LPN reported giving quetiapine for the resident’s aggression but did not know whether it was an approved treatment indication. The DON also noted that multiple residents in the facility were receiving antipsychotic medications.
A resident with chronic pulmonary embolism, pneumonia, HF, AFib, and SOB received PRN lorazepam multiple times, and the facility had active PRN lorazepam orders for restlessness or agitation that were not limited to the required 14-day stop date. The DON stated the facility policy limited PRN anxiety meds to 14 days and that the order was missed during review; no documented rationale for extending the order was provided by the end of survey.
A resident with dementia and anxiety received four extra doses of hydroxyzine after an agency LPN entered an order for three times daily dosing, despite the physician's directive to reduce the dose to twice daily. The LPN made this change without proper verification, resulting in the resident receiving unnecessary medication until the error was identified by an RN.
PRN psychotropic meds were not limited to 14 days for two residents. One resident with dementia and anxiety had a PRN lorazepam order with no stop date and repeated MAR administrations beyond the limit, while another resident with impaired cognition and multiple behavioral diagnoses had PRN Ativan and ABH gel orders set for 60 days. Staff stated the meds required reassessment after 14 days, but the orders continued past the regulatory timeframe.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.