Health inspection·January 5, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 2 of 4 residents reviewed for unnecessary medications review. (Residents #1 and #2). 1.Resident #1 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. 2. Resident #2 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary psychotropic medications . Findings included: 1.Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE]. Her diagnoses included: unspecified dementia with other behavioral disturbance (brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment with moodiness, personality changes, and aggression), delusional disorders (serious mental illness characterized by a person having one or more false beliefs, or delusions, that persist for at least a month) and anxiety. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1 had minimal difficulty hearing, unclear speech, usually understood others, and was usually understood by others. Resident #1 had a BIMS score of 1 indicating severe cognitive impairment. Record review of Resident #1's care plan dated 3/8/24 indicated she had impaired cognitive function related to dementia and the potential to be verbally aggressive. The care plan indicated she used psychotropic medications, Ativan, related to anxiety. The interventions included discussing ongoing use with the MD . Record review of Resident #1's physician's orders dated 12/2/24 indicated: Page 1 of 5 455684 455684 01/05/2025 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0758 2/8/24 Ativan oral tablet, 1 mg., Give 1 mg by mouth as needed for anxiety. Give TID as needed for anxiety/agitation. No end date. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's MAR for November 2024 indicated she had received Ativan 1 mg on: Residents Affected - Few 11/7/24 11/9/24 11/13/24 11/18/24 11/19/24 11/24/24 11/25/24 11/28/24 11/30/24 Record review of Resident #1's MAR for December 2024 indicated she had received Ativan 1 mg on: 12/4/24 12/7/24 12/8/24 12/9/24 12/10/24 12/11/24 12/13/24 12/14/24 12/16/24 12/17/24 12/18/24 12/20/24 455684 Page 2 of 5 455684 01/05/2025 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0758 12/23/24 Level of Harm - Minimal harm or potential for actual harm 12/26/24 12/28/24 Residents Affected - Few Record review of Resident #1's MAR for January 2025 indicated she had received Ativan 1 mg on: 1/1/25 1/4/25 2.Record review of the undated face sheet indicated Resident #2 was an [AGE] year-old female that admitted [DATE]. She had diagnoses that included: dementia (thinking and social skills that interferes with daily functioning), chronic pain, and abscess of chest wall (bacterial, funfal, or mycobacterial pathogen spreads through the blood to the chest wall). Record review of the quarterly MDS dated [DATE] indicated Resident #2 had clear speech, understood others, and was understood by others. She had a BIMS score of 7 indicating severe cognitive impairment. Record review Resident #2's care plan dated 4/10/24 indicated she had impaired cognitive function, dementia or impaired thought processes related to dementia. Resident #2 used antianxiety medications; Ativan related to anxiety disorder. Interventions included monitoring for side effects and effectiveness every shift. The care plan indicated she had a terminal prognosis related to having a stroke. Record review of Resident #2's physician's orders dated 12/2/24 indicated: 2/15/24 Lorazepam Intensol Oral Concentrate 2 mg/ml. Give 0.5 ml by mouth every 2 hours as needed for restlessness and give 1 ml by mouth every 2 hours as needed for restlessness. No end date. 2/21/24 Lorazepam oral tablet 0.5 mg, Give 0.5 mg by mouth every 8 hours as needed for anxiety. No end date. Record review of Resident #2's MAR for November 2024 indicated she not received PRN Lorazepam in November 2024. Record review of Resident #2's MAR for December 2024 indicated she received PRN Lorazepam 0.5 mg on: 12/28/24 12/29/24 Record review of Resident #2's MAR for January 2025 indicated she received PRN Lorazepam 0.5 mg on: 1/3/25 455684 Page 3 of 5 455684 01/05/2025 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/5/25 at 9:17 AM, LVN A, said Resident #2 received PRN Lorazepam and it was ordered in February 2024. She said she could not show where the medication was re-evaluated every 14 days. She said that type of medication should be re-evaluated every 14 days by the MD because it was a psychotropic medication. She said they monitored behaviors of residents on psychotropic medications. She said the risk of not re-evaluating psychotropic medication every 14 days was the resident could be overmedicated. During an interview on 1/5/25 at 9:26 AM, LVN B said Rresidents that were stable on Ativan/Lorazepam did not need a re-evaluation every 14 days. She said the residents that were unstable on the medications needed the medications re-evaluated every 14 days. She said if a resident was stable the medication should stay as is. During an interview on 1/5/25 at 10:42 AM, LVN C said Resident #1 had an order for Ativan PRN ordered 2/8/24, almost a year ago. She said she gave her the medication as needed. She said she was not aware of needing to re-evaluate psychotropic medication every 14 days. She said the danger of not re-evaluating psychotropic medication could be overmedicating the resident or possible addiction. During an interview on 1/5/25 at 11:21 AM, ADON D said PRN psychotropics should be re-evaluated by the MD every 14 days. She said she did not realize Resident #1 and Resident #2 were on PRN psychotropics. She said the risk of not re-evaluating the medications was the medication could be a chemical restraint, or cause increased falls/injuries, and oversedation. During an interview on 1/5/25 at 11:52 AM, ADON E said psychotropic medications were given per the Medical Director's order. She said some of the medication he wanted to be re-evaluated, and some he did not, based on the resident's behavior. She said she did not know if PRN psychotropics were supposed to be re-evaluated every 14 days. A risk for not re-evaluating psychotropic medication was the potential for it to be a chemical restraint. During an interview on 1/5/25 at 12:17 PM, the DON said PRN psychotropic medications should be re-evaluated every 14 days, but the MD's usually gave the orders and the NP's saw the residents weekly. The DON said there were no documented re-evaluations of the PRN medications for Resident #1 or Resident #2. She said the risk of not re-evaluating psychotropic medications would be different for each resident. She said a resident might be receiving a medication they did not need any longer, but that would be on an individual basis. During an interview on 1/5/25 at 12:29 PM, the ADM said PRN psychotropic medications should be re-evaluated every 14 days. She said that should have been done, and they were not following what they were supposed to do. She said the MD was not writing an evaluation or re-evaluation on the PRN psychotropics every 14 days. She said the risk of not re-evaluating the PRN psychotropic medication was keeping a resident on a medication they might not need. Record review of a Medication Management Policy and Procedure dated 10/1/19 indicated: Policy In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team 455684 Page 4 of 5 455684 01/05/2025 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition . F.As needed (PRN) orders include an indication for use. a.If the PRN medication is used to modify behavior, the indication(s) for use is clearly defined in objective terms, e.g., what specific symptom(s) is being addressed. b.The resident is monitored for the effectiveness of the medication or possible adverse consequence. Results are documented in the resident's active record. c.PRN orders for psychotropic drugs are limited to 14 days, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. d.PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. 455684 Page 5 of 5