Caritas Center, Inc

Based on interview, observation, and record review the facility

included:- R7's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The Quarterly MDS, dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition.

The MDS documented R7 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and had not received an antidepressant (a class of medications used to treat mood disorders) medication during the observation period.R7's Psychotropic Drug Use Care Area Assessment (CAA), dated 07/01/25, documented received Seroquel (antipsychotic medication) during the past hospitalization.

The physician decreased the Seroquel and ordered an antidepressant medication for anxiety.R7's Care Plan, documented:10/09/25 Sertraline (an antidepressant medication) increased the risk of suicidal thoughts and behaviors.The facility provided a signed physician order dated 10/09/25, which indicated the antipsychotic medication was discontinued during the previous observation period.R7's EMR under the Orders tab revealed a 02/12/26 dated physician orders for staff to administer 100 milligrams (mg) Sertraline (antidepressant medication), one tablet by mouth daily, for anxiety.Review of the Medication Administration Record (MAR) from 12/01/25 to 02/12/26 (74 days) R7 had received Sertraline 50mg daily.

Review of R7's MAR from 02/13/26 to 03/03/26 (19 days) revealed she had received Sertraline 100mg daily.On 03/04/26 at 11:02 AM, R7 sat in the recliner next to the open window. R7 stated she looked outside the window to watch the weather.On 03/04/26 at 11:15 AM, Administrative Nurse E stated she had marked R7's MDS in error related to R7 receiving an antipsychotic medication during the observation period.

Administrative Nurse E stated R7 had received antidepressant medication during that period.The facility's Conducting an Accurate Resident Assessment policy, dated 03/28/18, documented the center would ensure that all residents received an accurate assessment of relevant care areas.

Accurate assessments addressing each resident's status, needs, strengths, and areas of decline must be conducted by qualified staff that are knowledgeable about the resident and correctly document information about the resident's status.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE