The woman, who holds power of attorney for her father, discovered the facility had been administering Trazodone alongside melatonin to help the elderly man sleep. She never agreed to the psychotropic drug combination.
"Once, I came here and he was very lethargic and looked like a zombie," the daughter told inspectors on September 17. "When I asked what he had, I was told that he had Melatonin and Trazadone for sleep the previous night."
The patient has severe cognitive impairment from Alzheimer's disease and scored 7 on a mental status exam, indicating he cannot make medical decisions for himself. His daughter visits almost daily to oversee his care.
"Melatonin alone is just fine for my father to sleep," she said. "He is [AGE] years old. Why would they give my father both medications to sleep? I never consented for Trazadone and I am his POA."
Medication records show staff gave the man both melatonin 3 milligrams and Trazodone 50 milligrams on August 6. The orders ran from August 6, 2024 through August 9, 2025.
The facility's nurse manager admitted to inspectors they had no psychotropic consent forms for the patient.
"The purpose of doing the informed consent is to let them know if there are any adverse effects to the medication and to get signed consent to give the medication," the nurse manager said.
A registered nurse at the facility acknowledged the daughter's concerns about the sleeping medications and her complaints about how her father appeared during visits.
"She also wanted the Trazodone discontinued and complained that she didn't like the way that her father looked when she visited," the nurse told inspectors. "I don't give any psychotropic medication without consent from either the patient or the family."
Yet records show the facility did exactly that.
The patient came to Mercy Circle for rehabilitation while managing multiple conditions including Alzheimer's disease, delirium, coordination problems, walking difficulties and high blood pressure.
Federal regulations require nursing homes to obtain informed consent before administering psychotropic medications, which can significantly alter a person's mental state and physical functioning. The drugs carry risks of falls, confusion and other serious side effects, particularly in elderly patients with dementia.
Trazodone, originally developed as an antidepressant, is commonly used off-label as a sleep aid in nursing homes. The medication can cause drowsiness, dizziness, and what family members often describe as a drugged or zombie-like appearance.
The facility's own policy requires staff to inform residents and their representatives about the initiation, reason for use, and risks associated with psychotropic medications. The policy specifically references compliance with federal regulations governing these powerful drugs.
The daughter's description of her father as looking "like a zombie" reflects a common concern among families whose loved ones receive psychotropic medications without proper oversight. The lethargic state she observed aligns with known side effects of Trazodone, particularly when combined with other sleep aids.
Despite the nurse's claim that she doesn't give psychotropic medications without consent, the facility administered Trazodone to the patient for over a year without obtaining the required authorization from his power of attorney.
The violation occurred during the patient's rehabilitation stay, when his daughter was actively involved in his care and visiting regularly. Her frequent presence made the lack of communication about new medications particularly concerning.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the case highlights broader issues with medication management and family communication in nursing home settings.
The daughter ultimately succeeded in getting the Trazodone discontinued after confronting staff about her father's condition. She requested that only melatonin be used for sleep, a decision that should have been hers to make from the beginning.
The inspection found the facility failed to follow its own policies and federal requirements designed to protect vulnerable residents from unnecessary or harmful medications. The patient's severe cognitive impairment made proper consent procedures even more critical.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mercy Circle from 2025-09-18 including all violations, facility responses, and corrective action plans.