Surveyors found that the facility did not complete psychotherapeutic medication disclosure/consent forms for four residents before administering multiple psychotropic drugs, including antipsychotics, sedatives, antidepressants, and anxiolytics for conditions such as dementia with behavioral disturbance, MDD, anxiety, panic disorder, and psychosis. Record reviews showed that medications like Lorazepam, Seroquel, Clonazepam, Haldol, Hydroxyzine, Ramelteon, Risperidone, Mirtazapine, Caplyta, and Olanzapine were ordered and given without corresponding signed consent forms in the EHR. In an interview, the DON acknowledged that these residents should have had completed and signed consents and stated her expectation that residents or their representatives be informed about treatments and medications, including risks and benefits, before use.
A resident with mental health diagnoses, including anxiety disorder and PTSD, was receiving Gabapentin three times daily for anxiety/seizure disorder without a completed and signed psychotropic medication consent form, as required by facility policy. Review of records showed no consent form for Gabapentin, and the DON confirmed that all psychotropic medications should have a consent form and acknowledged that the absence of this form affected the resident’s right to be informed about the medication and its potential side effects.
A resident received multiple psychotropic medications, including Lorazepam for anxiety, Haldol for behavioral disturbances, and Seroquel for depression, without properly completed psychoactive medication consent forms signed prior to administration. Record review showed only one consent form in the EHR, covering Lorazepam on a single occasion, with no consents for other periods of Lorazepam use or for Haldol and Seroquel. In an interview, the DON confirmed that consent forms should have been completed before giving these medications but acknowledged this did not occur, placing residents at increased risk for side effects such as drowsiness, insomnia, fatigue, and sexual dysfunction.
The facility did not obtain required informed consent for multiple psychotropic and related medications given to several residents. One resident received melatonin for insomnia without a documented consent form. Another resident was given melatonin for insomnia and alprazolam for anxiety/restlessness with no corresponding consent forms in the record. A third resident received melatonin for insomnia, olanzapine for schizophrenia, and gabapentin for pain/bipolar disorder, again without any documented consents. In each case, the DON acknowledged that staff failed to complete the expected psychotropic medication consent forms before starting these medications.
The facility failed to obtain and document informed consent before administering psychotropic medications to three residents. Multiple anti-anxiety and other psychotropic drugs, including Buspirone, Clonidine, Lorazepam, Hydroxyzine, and Quetiapine, were ordered and given without signed psychotropic consent forms in the EHR. Pharmacist reviews for each resident noted that informed consent should be obtained at admission, prior to starting a psychotropic, or before dose increases, and that no consent forms were found. Psychotropic consent forms were later created and signed weeks to months after medication initiation, with consent dates documented as if obtained earlier. An LPN reported that the ADON was responsible for completing these consent forms prior to administration, and both the ADON and a regional nurse consultant acknowledged that consents were not completed before the medications were given.
A resident was started on two psychotropic medications, Lorazepam and Hydroxyzine, for anxiety without documented informed consent. Record review showed active orders for both medications, but no corresponding consent forms in the medical record. The DON acknowledged that staff did not complete the required psychotropic medication consent process before initiating these drugs, despite the facility’s expectation that consent be obtained prior to starting psychotropic therapy.
A resident with severe cognitive impairment and a diagnosis of unspecified dementia with agitation received Risperdal 1 mg daily over several months without documented informed consent, despite facility policy requiring consent for psychotropic medications used to manage behavioral symptoms. Physician orders and MARs showed continuous Risperdal administration for delusions, mood changes, and dementia-related agitation, while the record contained consent forms only for other antipsychotics (Quetiapine and Seroquel). The DON reported that staff are expected to obtain resident or family consent for psychotropic medications within 24 hours and acknowledged that no consent form for Risperdal was present for this resident, contrary to facility policy.
A resident was prescribed clonazepam 0.5 mg once daily for insomnia, but the medical record contained no documented consent for this psychotropic medication. Review of records showed that the resident and/or representative had not been informed in advance about the medication’s reasons, risks, and benefits. In an interview, the DON confirmed the absence of consent and acknowledged that consents should be completed for psychotropic active medications.
A resident with a chronic sacral pressure ulcer repeatedly refused wound care during the night shift, expressing a preference for daytime care. Despite these requests, staff continued to attempt wound care at night, and there was no documentation of any change to the care plan or physician orders to accommodate the resident's wishes. Nursing notes and interviews confirmed the resident's refusals and preferences, but the facility did not adjust care practices or document reasons for missed wound care.
Two residents were administered psychotropic and related medications, including antidepressants, anticonvulsants, antianxiety, and antipsychotics, without documented informed consent forms in their medical records. The DON confirmed that such consent should have been obtained and documented to ensure residents or their guardians were aware of the reasons, risks, and benefits of each medication.
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 June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account