F758 · Psychotropic drugs

Based on interview and record review, the facility failed to carry out critical medication level monitoring that was ordered and failed to consider whether the onset or worsening of symptoms, or a change of condition, may be related to the medication and failed to respond to the presence of adverse consequences related to the use of a high-risk medication for 1 of 3 sampled residents [Resident #1], which resulted in Resident #1's death. This citation is at the immediate jeopardy level due to the lack of an effective process to ensure medications are only administered with adequate monitoring of laboratory values, per manufacturers specifications and accepted professional standards for high risk medications, and not administered in the presence of adverse consequences which indicate the… …

Bennington Health & Rehab · Vermont

Based on interview and record review the facility failed to ensure residents entire drug/medication regimen was managed and monitored to promote or maintain their highest practicable mental, physical, and psychosocial well-being for 3 of 4 Residents (Residents 1, 2, & 38) who received psychotropic medications. Resident 1 experienced harm when the facility continued to administer antipsychotic medication without an approved clinical indication, evaluation of appropriateness, consideration for approved alternative treatments, monitoring, or evidence of non-pharmacological approaches that resulted in psychosocial and physical harm when they were transferred to the hospital due to altered mental status from the adverse effects of antipsychotic medication and was found to have an acute hip… …

Alaska Gardens Health and Rehabilitation · Washington

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 4) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). Failure for the facility to obtain informed consent for treatment with psychotropic drugs and to ensure Resident 4 was monitored for adverse side effects, placed residents at risk of not being fully informed of the risks and benefits of treatment with psychotropic drugs and to receive unnecessary psychotropic drugs. Findings included . Review of a facility assessment, dated 03/14/2025, showed Resident 4 had diagnoses which included Cellulitis (an infection of the skin and tissues beneath) of their lower legs, anxiety, and depression. …

Spokane Falls Care · Washington

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was provided the non-pharmacological interventions for the use of psychotropic medication (medication that affects the mind, emotions, and behavior). This failure had the potential to result in the unnecessary use of psychotropic medications for Resident 1. Findings: Review of the facility's P&P titled Antipsychotic Medication Use (undated) showed for enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions. …

Crystal Cove Care Center · California