This study examined associations of COVID-19 mortality rates, staffing, and resident behavior with changes in antidementia and psychotropic medication initiation among nursing home (NH) residents with dementia. A nationally representative survey of Directors of Nursing was analyzed to assess changes in medication initiation at the peak of the pandemic. NHs with higher COVID-19 mortality rates were less likely to report increases in antidementia medication initiation. COVID-19 mortality rates were not associated with significant increases or decreases in psychotropic initiation. NH's that reported increased resident behavioral problems during the pandemic had higher odds of psychotropic initiation. In summary, NHs most affected by COVID-19 deaths were less likely than NHs with a milder pandemic experience to increase initiation of antidementia medications. Increased behavioral symptoms, possibly due to consequences of COVID-19, were associated with more psychotropic drug use. More research is needed to understand factors influencing prescribing practices during public health emergencies.