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.
The facility failed to ensure a PRN psychotropic medication had a 14-day stop date for a resident receiving Lorazepam for anxiety. The MAR showed the medication was given multiple times, and the DON stated hospice residents were not given stop dates even though the facility policy required PRN psychotropic orders to be limited to 14 days.
Two residents were prescribed and administered Seroquel for dementia-related diagnoses, contrary to facility policy that restricts antipsychotic use to specific, indicated conditions. An LPN reported the medication was used for behavioral issues, while the DON confirmed antipsychotics are not approved for dementia treatment. Despite this, multiple residents were receiving these medications for dementia.
Psychotropic medication management was not followed for multiple residents. One resident had duplicate trazodone dosing that staff did not clarify, another resident received PRN lorazepam without the required 14-day stop date or prescriber rationale for extended use, and a third resident continued receiving both doxepin 6 mg and 10 mg despite an order to stop the 6 mg dose once the 10 mg was available. Staff interviews showed confusion about the orders and the DON/ADON acknowledged the errors.
A resident with dementia, anxiety disorder, and PTSD was administered both 1 mg and 0.5 mg doses of Risperdal after a dose reduction order was written but the original higher dose was not discontinued. The resident did not understand why the medication was being given and expressed a desire not to take it. The DON confirmed the unnecessary administration resulted from a failure to discontinue the previous order.
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