A resident with schizophrenia, bipolar disorder, severe intellectual disabilities, and severely impaired cognition had an order to monitor Haloperidol and Invega outcomes each shift using I, S, or W. An LPN entered 0 instead of the ordered alphabetic code on multiple shifts, and the ADON and DON confirmed the entries were incorrect and did not match the prescriber order.
A resident with severe cognitive impairment and diagnoses including traumatic subdural hemorrhage and cerebral infarction had a PRN lorazepam order for anxiety with no end date listed. The DON stated the order should have had a 14-day stop date and been reevaluated for extension, and the Administrator acknowledged the PRN order should have had an end date.
A resident with dementia and severe cognitive impairment was receiving Zyprexa for anxiety/agitation and aggressive behavior related to restlessness and agitation while on hospice. The MAR and care plan documented the antipsychotic use, but the NP and DON acknowledged the resident did not have a diagnosis of psychosis, schizophrenia, or bipolar disorder, and the medication’s listed indication did not match the resident’s documented diagnosis.
Failure to document GDR attempts for psychotropic meds: two residents receiving clonazepam and citalopram had no clear evidence of GDRs or clinical contraindications in the record. The consultant pharmacist recommended dose reductions, but the only response documented was that psych follows and manages meds, with no clear supporting documentation from the psychiatry provider or care plan evidence of prior/future GDR planning.
PRN Psychotropic Order Lacked Required 14-Day Limit: A resident with vascular dementia, severe cognitive impairment, and anxiety had a PRN Ativan order for agitation with no stop date. The chart also included a pharmacy note stating CMS requires evaluation of PRN psychotropic orders beyond 14 days, while the DON and ADM stated PRN psychotropic meds should be reviewed every 14 days and acknowledged the order was not reviewed and corrected.
PRN Psychotropic Order Lacked Required 14-Day End Date: A resident with anxiety, depression, and respiratory failure had a PRN Xanax 0.25 mg order for anxiety, restlessness, and agitation that was entered without a 14-day end date. The DON and Administrator stated PRN psychotropic meds should have a 14-day end date, and no specific policy addressing the deficient practice was provided.
A resident receiving hospice care had a PRN Ativan order for anxiety that was entered without the usual 14-day stop date. Staff, including the LVN, Unit Manager, Pharmacy Nurse, and DON, acknowledged that PRN anti-anxiety orders normally require a stop date, but they believed hospice status exempted the order. The resident had a diagnosis of anxiety and had received the medication several times, while the facility policy stated PRN psychotropic meds must be limited to 14 days unless the prescriber documents an extended duration.
PRN psychotropic orders were not limited to 14 days for two residents. One resident with Alzheimer’s disease and anxiety and another resident with dementia, depression, and anxiety both had PRN lorazepam orders that remained active without stop dates, and the DON stated there was no documentation supporting continued use beyond 14 days. The ADM and DON said staff were responsible for ensuring the 14-day limit was met, but the orders remained in place without the required documentation.
Unnecessary antipsychotic use for residents with dementia. The facility administered antipsychotic medications to multiple residents with dementia and severe cognitive impairment, including olanzapine, risperidone, and quetiapine, for broad indications such as psychosis, affective mood disorder, and mood disorder. Records showed routine administration despite diagnoses of Alzheimer’s disease or dementia, and staff stated they relied on provider diagnoses and did not question the indication unless behaviors or family concerns arose.
A resident with Alzheimer’s disease, psychotic disorder with hallucinations, Parkinson’s disease, and major depression was receiving mirtazapine via PEG tube, but the facility did not complete a GDR review for the psychotropic medication. The DON stated the resident was not on psych services and could not find a GDR, while the RDHS and DON reported pharmacy had reviewed the medication with no changes recommended but no physician review had been completed. The facility policy required GDRs and behavioral interventions unless clinically contraindicated, including attempts in two separate quarters within the first year after admission or medication initiation.
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 October 8, 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.