Federal inspectors cited Belmont Terrace for medication management failures affecting three residents during a November complaint investigation.
The most dramatic case involved a resident whose escitalopram was discontinued without proper consultation. Progress notes from August documented the resident "had episodes of being terribly upset and crying" and required as-needed medications.
When staff called the resident's guardian for consent to restart the antidepressant, the guardian voiced anger that the medication was ever stopped. The guardian told staff "to not stop it again and said the resident was on hospice and should be happy and comfortable."
Staff B, the registered nurse and director of nursing, admitted to inspectors he "could not explain why they discontinued the escitalopram." He acknowledged staff should have ensured the provider discussed the gradual dose reduction with the guardian or discussed keeping the resident on the medication.
"Either way there should have been a discussion," Staff B told inspectors.
The facility also failed to act on consulting pharmacist recommendations for two other residents taking psychiatric medications.
A second resident diagnosed with chronic obstructive pulmonary disease and Alzheimer's disease was supposed to have his aripiprazole reduced from 10 mg to 2 mg daily. The antipsychotic medication treats bipolar disease and schizophrenia.
A consultation report from June documented the resident was due for a gradual dose reduction. The recommendation included reducing the aripiprazole to 2 mg daily, and the physician checked "I accept the recommendations above, please implement as written" on June 26.
But medication administration records showed the resident continued receiving the full 10 mg dose daily throughout July, August, and September. Order summaries confirmed the 10 mg dose had been in place since August 2024.
Staff B verified to inspectors the medication was never reduced as recommended. "This GDR should have been acted on per the recommendations," he said.
A third resident with congestive heart failure and morbid obesity was prescribed bupropion for depression and insomnia. Her care plan noted staff would monitor for social isolation, tearfulness, and heightened awareness.
The consulting pharmacist recommended a trial discontinuation of the antidepressant in June. The physician accepted the recommendation and signed the document on June 27, but provided no specific instructions for staff to discontinue the medication.
The resident continued receiving bupropion 75 mg daily through August, according to medication administration records. Order summaries showed she had been on the same dose since August 2024.
Staff B acknowledged the order should have been clarified and acted upon. "This should have been followed up on," he told inspectors.
The inspection found the facility failed to ensure medications were administered according to physician orders and consulting pharmacist recommendations. Gradual dose reductions are designed to minimize withdrawal effects and monitor residents for changes in behavior or symptoms.
For the hospice resident whose antidepressant was abruptly stopped, the consequences were immediate and distressing. The resident experienced emotional episodes that required additional medications to manage, contrary to the guardian's wishes for comfort and happiness during end-of-life care.
The other two residents continued receiving psychiatric medications at doses their physicians had approved for reduction or discontinuation, potentially exposing them to unnecessary side effects from drugs they may no longer have needed.
Staff B's admissions to inspectors revealed systemic communication breakdowns between the nursing staff, consulting pharmacists, and physicians. The director of nursing could not explain why medications were stopped inappropriately in one case or why physician-approved recommendations were ignored in the others.
The violations occurred despite care plans documenting the residents' mental health conditions and the need for careful monitoring of their psychiatric medications and behavioral symptoms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belmont Terrace from 2025-11-18 including all violations, facility responses, and corrective action plans.