The Centers for Medicare and Medicaid Services initiated three strategies (in March and July 2012 and in May 2013) to reduce the use of unnecessary antipsychotic medications in nursing homes, especially their widespread use to control behavioral symptoms of dementia. We examined 86,163 state recertification surveys conducted at 15,055 facilities in the period January 1, 2009–March 31, 2015. We found that these strategies were associated with increases in citations for only one of two targeted deficiencies (unnecessary drug use) and only after the third strategy (revisions to the federal guidelines for the citations) was implemented. Each strategy was associated with a modest but significant reduction in antipsychotic prevalence in the general nursing home population. Initial reductions were greater in the ten states with the highest prevalence of antipsychotic use in nursing homes, compared to the ten states with the lowest prevalence. Use of other psychoactive medications, some of which are potential substitutes for antipsychotics, varied with each strategy and by state. Continuous monitoring and consistent enforcement are needed to ensure the continued decline in unnecessary use of antipsychotics and psychoactive medications in nursing homes.