Nye Summit switched Resident 7 from Elavil to Quetiapine on November 5, 2024, for a diagnosis of primary insomnia. The facility's medical records contained no sleep test, sleep diary, or sleep assessment to justify the prescription change.
Quetiapine is not approved by the FDA for treating insomnia.
The resident had been taking Amitriptyline, known as Elavil, but staff discontinued it and started the antipsychotic instead. Records showed no documented sleep problems or insomnia behaviors while the resident was on the original medication.
Twenty days after the prescription began, the facility's consulting pharmacist sent an urgent recommendation to discontinue Quetiapine. The pharmacy warned that the drug "can cause abnormal muscle movements and life-threatening neuroleptic malignant syndrome," a reaction that triggers muscle stiffness, high fever, altered mental status, irregular heart rhythms, and respiratory failure.
The pharmacist recommended switching to Trazadone, a depression medication commonly used off-label for sleep problems with fewer risks.
Nobody responded to the pharmacy's warning.
The facility's Assistant Director of Nursing confirmed in a January interview that the provider never replied to the pharmacist's recommendation. She said it typically "takes months for that provider to address pharmacy recommendations" and admitted staff had not attempted to contact the provider directly about the safety concerns.
The ADON acknowledged the prescription change was inappropriate. "The provider should not have changed the resident from Elavil to Quetiapine on 11/05/2024 without documentation of behaviors or doing the sleep diary," she told inspectors.
Resident 7 used an outside physician rather than the facility's medical provider. The ADON said if the resident had used the facility's doctor, "they would have done all the other needed steps" including proper assessments.
Federal regulations require nursing homes to monitor residents taking psychotropic medications through regular safety assessments. Nye Summit failed to complete a required psychotropic assessment for Resident 7 after starting the Quetiapine.
The facility's last Abnormal Involuntary Movement Scale evaluation, used to detect dangerous muscle movement side effects, was completed October 28, 2024 — before the antipsychotic prescription began.
The consulting pharmacist confirmed to inspectors that Quetiapine "is not approved for the treatment of Insomnia and would not be a primary medication." The pharmacist said the drug could potentially be used for sleep problems only "if the provider provided good enough rational."
No such justification existed in the resident's medical records.
The pharmacist had recommended a sleep assessment be completed during a Quality Assurance and Performance Improvement meeting. When inspectors arrived, facility staff confirmed no assessment had been done and acknowledged it "should have been for that medication."
Inspectors found additional safety violations throughout the facility during their January visit.
In the kitchen, staff failed to label and date opened food packages, creating risks of foodborne illness for all 47 residents. Inspectors discovered undated bags of lettuce and celery, exposed turkey slices, unknown meat in unmarked containers, and two packages of undated cheese in the walk-in refrigerator.
A container of cooked vegetables bore a date indicating the food had expired, but kitchen staff had not discarded it.
The walk-in freezer contained an open bag of French fries exposed to air, plus zip-lock bags of unidentified white and brown substances with no dates or labels.
The Dietary Manager confirmed all the undated items should have been properly labeled and acknowledged the expired vegetables should have been thrown away.
Ventilation systems failed in 14 occupied rooms on the facility's 200 hallway, affecting bathrooms used by 20 residents. The Maintenance Director tested each bathroom by holding toilet paper against ventilation covers — none of the paper held, indicating no air circulation.
"The ventilation system was not functioning in the bathrooms on the 200 hallway and the ventilation system should be working," the maintenance director told inspectors.
The facility housed 48 residents at the time of inspection.
Federal inspectors classified the medication violation as having potential for actual harm but affecting few residents. The food safety and ventilation problems were rated as having potential for actual harm affecting many residents.
Resident 7 continued taking Quetiapine without proper monitoring or safety assessments as of the inspection date, more than two months after the pharmacy's urgent warning about life-threatening side effects.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nye Summit from 2025-01-13 including all violations, facility responses, and corrective action plans.