Inspection·June 2, 2022

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to adequately monitor resident behaviors for one resident (#16) receiving antipsychotic medications from a total sample of 11 residents. Residents Affected - Few The findings include: A review of Resident #16's medical record revealed an admission date of 6/22/19 with a readmission on [DATE]. Her diagnoses included Alzheimer's disease, drug-induced subacute dyskinesia; other muscle spasms; depressive disorder, non-Alzheimer's dementia, and anxiety disorder. A review of the May 2022 Physician's Order Sheets revealed an active order for Quetiapine (Seroquel antipsychotic) 25 milligrams (mg) at hour of sleep and monitor for side effects. The medical record did not reveal any orders for behavior monitoring for the ordered medication. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/2/22, revealed that Resident #16 received antipsychotic medication on seven of seven days during the assessment lookback period. She also received antidepressant, hypnotic and opioid medications during that time. A review of the May 2022 Medication Administration Record (MAR) revealed no monitoring of behaviors for the administration of antipsychotic (Quetiapine/Seroquel) medication. A review of the active care plan revealed a focus area for: Intermittent confusion, delusions, behaviors, related to Alzheimer's dementia with interventions for medications as ordered; document for side effects and effectiveness; review medications and records for causes of cognitive deficit. Prescribed psychotropic medications, related to behavior management, dementia, neuropathic pain, and chronic pain, anxiety, history of delusional thinking; administer medications as ordered by physician, monitor for side effects and effectiveness every shift; monitor/record occurrence of target behavior symptoms, refer to the physician's order and MAR. On 5/31/22 at 10:48 a.m., an interview was conducted with Agency Licensed Practical Nurse (LPN) A. When asked if monitoring of behaviors was expected for residents receiving antipsychotic medications, LPN A stated, yes. She stated side effects and behaviors were two separate orders and they were to be documented on the MAR. On 6/2/22 at 10:50 a.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #16. She stated there should be an order and documentation for side effects and behavior monitoring for antipsychotic medications. She stated she did not see current documentation for behavior (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: 106040 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 106040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster St Augustine 230 Towerview Drive Saint Augustine, FL 32092 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)