Health inspection·March 23, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm 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** Resident #1 Residents Affected - Some Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that two of seven residents (Resident #1 and Resident #47) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #1 continued to have a PRN order for Lorazepam 1mg after 14 days without an evaluation by the physician for continued treatment. - Resident #33 continued to have a PRN order for Xanax 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Record review of Resident #1's face sheet, dated 3/21/23, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: dislocation left hip, anxiety, muscle weakness and pain. Record review of Resident #1's physician orders, dated 2/27/23, revealed an order for Lorazepam 1mg 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 10/11/22. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Section N - Medication Section

N0410 - Medications Received: B - Antianxiety - Given 7 out of 7 days. Record review of Resident #1's MAR from March 2023 revealed Lorazepam 1mg give 1 tablet by mouth every 4 hrs. as needed for anxiety was administered on 3/1/23, 3/17/23 and 3/18/23. Record review of the pharmacy consultant book from January 2023 to March 2023 revealed no pharmacy recommendations related to Resident #1's PRN Lorazepam. Page 1 of 3 675061 675061 03/23/2023 Munday Nursing Center 421 West F St Munday, TX 76371

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #33's face sheet, dated 3/23/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Parkinson's disease (brain disorder) and benign neoplasm of meninges (brain tumor) Record review of Resident #33's physician orders, dated 2/27/23, revealed an order for Alprazolam (Xanax) 0.5mg 1 tablet by mouth PRN every 8 hours as needed for anxiety with a start date of 11/15/22 and no end date. Record review of Resident #33's quarterly MDS, dated [DATE], revealed Section N - Medication Section

N0410 - Medications Received: B - Antianxiety - Given 7 out of 7 days. Record review of Resident #47's MAR from March 2023 revealed Alprazolam 0.5mg 1 tab PO PRN was currently ordered with a start date of 11/15/22 and an indefinite end date. Record review of the pharmacy consultant book from January 2023 to March 2023 revealed no pharmacy recommendations related to Resident #33's PRN Alprazolam. Interview on 3/22/23 at 1:00 PM, the DON stated that she was responsible for ensuring PRN antipsychotic medications were not extended beyond 14 days. The DON stated that both residents were on hospice services and the orders were just looked over. The DON stated the residents had an increased risk for sedation and over-medication due to an extended PRN antipsychotic medication order. Interview on 3/23/23 at 8:47 AM, the Admin stated it was the responsibility of the DON to check on PRN psychotropic medications. The Admin stated she does not know how this failure occurred and believes the orders were overlooked due to the residents being on hospice. The Admin stated that the residents were at risk of over sedation related to the psychotropic PRN medications. Record review of facility policy titled, Antipsychotic Medication Use with a revised date of December 2016 reflected the following: Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation: .13. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication 675061 Page 2 of 3 675061 03/23/2023 Munday Nursing Center 421 West F St Munday, TX 76371

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food orally from 1 of 1 facility kitchen in that: Perishable ready to eat foods were held beyond safe use dates (boiled eggs). These failures could place residents at risk of foodborne illness. The findings include: The following kitchen observation were made beginning on 03/21/23 at 9:30 AM and concluding at 10:15 AM: Observed two bags of boiled eggs dated 3/2 in the top shelf of the refrigerator. During an interview with the DM on 03/21/23 at 02:37 PM she stated the eggs could be stored in refrigerator for one month. During an interview with the DM on 03/22/23 at 09:50 AM she stated she had thrown the boiled eggs out because they can only be stored or 7 days. During an interview with the DM on 03/23/23 at 08:30 AM she stated perishable foods without an expiration date can only be stored for 7 days. She stated it is everyone's responsibility to monitor perishable foods stored in refrigerator and throw out after 7 days. She stated all staff have been trained to date food stored in refrigerator and throw out after 7 days. She stated the potential negative outcome for storing foods longer than 7 days could be bacteria can grow and make the residents sick. During an interview with the Admin on 03/23/23 at 08:49 AM she stated perishable foods stored in the refrigerator can only be stored for 7 days. She stated it is everyone responsibility to monitor the food in the refrigerator and the DM should be following up. She stated the potential negative outcome of storing foods past 7 days could be food borne illness and the residents could become ill. Record review of a policy provided by facility titled Storage of Frozen and Refrigerated Foods with a revised dated 12/4/2006. Policy: Potentially hazardous foods will be refrigerated or frozen using proper procedures. Procedure: 9. Refrigerate foods in shallow containers to speed the cooling process. Label to date placed in the refrigerator, time, expiration or use by date. Once a product has been opened the date opened shall be written on the product and use by date is 7 days from date opened. Food prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 7 days from the date prepared. 12. Manufactured refrigerated items such as cooked eggs, cheese, lunch meat, when opened are to be placed in a sealed container, labeled to opened date and use by date (7days). 675061 Page 3 of 3