Washington — The federal investigation into antipsychotic drug misuse in nursing homes sent a jolt through the long-term care industry last week. Now, facilities are being asked a harder question: what do you actually do about it?
A growing chorus of compliance experts and industry advocates is laying out a road map — and it starts with understanding where the real line is between appropriate care and chemical restraint.
New Scrutiny, Old Tensions
The antipsychotics issue has dogged nursing homes for years. Federal regulators have long tracked the percentage of long-stay residents receiving these medications as a quality measure, using it to calculate star ratings on Nursing Home Care Compare. The problem? The metric doesn’t distinguish between residents who need the medication for legitimate psychiatric conditions and those who may be receiving it to manage behavioral symptoms from dementia.
That distinction has frustrated providers for years, and it’s now at the center of a larger policy fight.
After federal investigators concluded that thousands of nursing homes had been faking schizophrenia diagnoses to mask inappropriate antipsychotic use and boost their star ratings, the pressure on CMS to act intensified sharply.
What CMS Changed — and What It Didn’t
CMS updated its surveyor guidance on antipsychotic medications in April 2025, strengthening the responsibilities placed on medical directors and setting clearer standards for when psychiatric diagnoses can be made and when antipsychotics can be prescribed. Surveyors now have more specific guidance on what to look for during inspections.
But facilities are still navigating a quality measure that many argue is too blunt.
Jodi Eyigor, vice president of health policy at the American Health Care Association and National Center for Assisted Living, called on CMS to rethink how it tracks the issue. Her position: the agency needs to separate appropriate antipsychotic use from inappropriate use before punishing facilities across the board.
“These are complex issues that require continued thoughtful examination of how current structures contribute to the problem,” Eyigor said in a statement. “Nursing home residents should never be subject to chemical restraints and residents with distressing neuropsychiatric symptoms should have access to both drug and non-drug therapies.”
The Compliance Tightrope
For nursing home operators, the current environment creates a difficult balance. Pull back on antipsychotics to improve your quality score — and you may be undertreating residents with real psychiatric needs. Maintain appropriate prescribing — and you risk getting flagged in an audit climate that’s tighter than ever.
Compliance experts say the clearest path forward is documentation. Every decision to prescribe an antipsychotic needs to be grounded in a legitimate clinical diagnosis, signed off by the attending physician or medical director, and reviewed regularly. That documentation trail is what protects a facility when a surveyor or OIG auditor comes through the door.
Non-pharmacological approaches to managing behavioral symptoms — structured activities, sensory interventions, consistent staffing — are also getting renewed attention as facilities look to reduce their antipsychotic numbers without leaving residents without support.
CMS Still Has Decisions to Make
CMS has signaled it may revise or replace its current antipsychotic quality measure entirely, but no timeline has been announced. In the meantime, operators are left managing a metric that everyone agrees needs work — while bracing for federal surveys that are, by any measure, more aggressive than they were a year ago.
The message from advocates and compliance specialists alike is consistent: the goal isn’t to avoid antipsychotics. It’s to earn every prescription you write.
