F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on review of resident records, interview, and review of facility policy, the facility failed to obtain
consent for 1 of 2 psychotropic medications ordered for 1 of 3 residents reviewed for psychotropic
medication usage. (Resident #3)
The findings included:
On 3/4/24, a review of the records for Resident #3 was conducted. A review of the Medication
Administration Record in December 2024 indicated that, in addition to Mirtazapine (an antidepressant) 30
mg once a day, Resident #3 had been taking Trazadone (another antidepressant) 50 mg .5 tablet every 8
hours. Resident #3's record had a signed consent to take Mirtazapine 30 mg once a day. However, there
was no consent for the Trazadone.
A review of the psychiatric notes, dated 9/26/24, for Resident #3 was conducted. The psychiatry notes
stated that Resident #3 was started on Trazodone due to an exacerbation of depression and mood
disorder. The note indicated that medication changes were needed to stabilize his symptoms. The provider
indicated that risks, benefits, and alternatives were discussed. The note does not clarify whom the risks,
benefits, and alternatives were discussed and if consent was verbally obtained from the resident's
representative. Trazodone 25 mg po three times a day was instantiated in addition to the Mirtazapine for
agitation.
A review of the psychiatric notes dated 11/21/2024 revealed, Prior to last visit, resident had excessive
sedation and was not wanting to eat. Trazodone 25 mg three times a day (TID) as needed (PRN) was
started for 30 days. Trazodone 25 mg by mouth three times a day was discontinued as per the patient
representative request. There was no note indicating that risks, benefits, or consent was obtained when the
Trazadone dosing was changed from three times a day (TID) to three times a day as needed (PRN).
A review of the orders was conducted for Resident #3. An order was placed on 9/27/24 for Trazodone 25
mg by mouth three times a day for major depressive disorder. The order end date was on 10/17/24. On
10/17/24, there was an order for Trazodone 25 mg to be given by mouth every 8 hours as needed for major
depressive disorder for 30 days. The order end date was 11/17/24. There was also an order for Trazodone
50 mg half a tablet by mouth every 8 hours for major depressive disorder, start date 11/23/24 and end date
12/4/24. On 12/2/24, there was an order to hold the medication until further notice. A note entered with the
order indicated that the medication needed to be discontinued. The order and note was written by the
medical provider.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105433
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Tallahassee
3101 Ginger Dr
Tallahassee, FL 32308
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/5/25 at 2:50 PM an interview was conducted with the Director of Nursing (DON). She was asked for a
copy of the consent for the resident's Trazodone. The DON indicated that consent was not needed for
Trazodone because it was an antidepressant. Although the facility had a consent for the Mirtazapine 30 mg
once a day for depression, the DON reiterated that a consent was not needed for antidepressants.
On 3/6/25 at approximately 9:30 AM, an interview conducted with the facility psychiatric nurse practitioner
provider, who provided psychiatric services to Resident #3. She was informed about concerns regarding
finding no consent for the Trazadone in the patients record. A consent for Mirtazapine was in the record of
Resident #3, but not the Trazadone. The nurse practitioner indicated that she remembered the client and
she explained the risks and the benefits of the medication Resident #3's representative before the
Trazodone was initiated. The nurse practitioner indicated that the Trazadone was an antidepressant and
therefore a psychotropic medication just like the Mirtazapine.
On 3/6/25, a review of the facility policy and procedure titled Medication Management Psychotropic
Medications, dated 10/24/2022, was conducted. The procedure section of the policy stated that residents
receiving psychotropic medications will have the risk/benefits reviewed and consent completed prior to
initiation of the medication. The policy further indicated that as needed (PRN) orders for psychotropic
medications were to be limited for 14 days except when the prescribing practitioner believes that is
appropriate to extend the medication beyond 14 days and documented the rationale and indicates the
duration of the prn medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105433
If continuation sheet
Page 2 of 2
