Health inspection·June 15, 2023

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an irregularity noted by the pharmacist was acted upon for 1 (Resident #4) of 6 residents reviewed for pharmacy review. The facility failed to ensure: 1. The pharmacist's Physician Notification Letter dated 03/07/2023 reflected Resident #4 had a routine order for a medication (Robitussin Nighttime DM [Dextromethorphan]) that was not recommended for routine use in the elderly. 2. The pharmacist's Physician Notification Letter dated 05/09/2023 reflected Resident #4 was still receiving the medication routinely as of 6/14/23. The physician signed the 05/09/2023 letter, agreeing to discontinue the routine administration of the medication . These failures could place residents at risk for complications resulting from receiving a medication contraindicated for routine use. Findings Include: Record review of the admission Record (printed 06/15/2023) revealed Resident #4 was 84-years-old, admitted to the facility on [DATE]. Diagnoses included muscle weakness, asthma (breathing difficulty), insomnia (difficulty sleeping), and chronic respiratory failure (breathing difficulty). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she scored 15/15 on the BIMS, indicative of intact cognition. She required limited assist for bed mobility and transfers. She used a wheelchair for mobility. The MDS reflected Resident #4 received a hypnotic (medication to help sleep) for all seven days of the seven-day look-back period. Record review of Resident #4's Care Plan dated 05/16/2023 read in part . Resident #4 receiving a sedative or hypnotic . Goal: the resident will be free of any discomfort or adverse side effects. Intervention: Administer sedative/hypnotic medications as ordered by the physician . Record review of Resident #4's Medication Regimen Review note dated 03/07/2023 read in part that a Physician Notification Letter was sent on 03/07/2023 . Record review of Resident #4's pharmacy Physician Notification Letter dated 03/07/2023 read in part that Resident #4 was receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at Page 1 of 7 676282 676282 06/15/2023 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bedtime for cough. The letter reflected .Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula) . Accept/decline' and physician signature areas were blank. Record review of Resident #4's Medication Regimen Review note dated 04/12/2023 read in part Check for response to 3/7/2023 letter to PCP to stop routine Robitussin Nighttime cough. Follow up: change the medication to PRN . Record review of Resident #4's Medication Regimen Review note dated 05/09/2023 read in part . Re-send the letter to discontinue the routine Robitussin Nighttime DM. Nurse Follow-Up: Noted . Record review of Resident #4's pharmacy Physician Notification Letter dated 05/09/2023 read in part . Receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula). Accept/decline' and physician signature areas marked 'accept' and scribed D/C Robitussin Nighttime DM by Nurse Practitioner (05/11/2023) . Record review of Resident #4's Medication Regimen Review note dated 06/13/2023 read in part . Routine Robitussin Nighttime DM medication to be discontinued . Record review of Resident #4's MAR dated June 2023 read in part . Routine Robitussin Nighttime Cough DM . The MAR reflected Resident #4 received the medication every night up to 06/13/23 . Observation and interview on 06/14/2023 at 3:40 p.m., the DON said per the facility protocol for pharmacy reviews, she was responsible for reviewing the Medication Regimen Review notes, then on the following day she gave the Physician Notification Letters to the physician. She said the recommendations were to be implemented within seven days. The Surveyor presented Resident #4's pharmacy review note scribed in nurse's follow-up notes on 4/12/23. The DON said the note scribed in the 04/12/2023 Nurse Follow-Up area for the medication to be changed to PRN was her writing. This Surveyor asked if Resident #4 was still receiving the routine Robitussin medication. The DON pulled up the electronic MAR dated June 2023. She verbally acknowledged Resident #4 was still receiving the routine Robitussin Nighttime Cough DM nightly. Interview on 06/14/2023 at 3:50 p.m., the DON said she had spoken to Resident #4, and the resident wanted to receive the medication every night. When asked if the physician had been informed, the DON said she would notify the physician at this time. Interview on 06/15/2023 at 3:15 p.m., the DON said the Charge Nurse was responsible to update the orders when a pharmacy recommendation was received. She said the order for Resident #4 had just been overlooked. Record review of the facility policy Medication Regimen Review (revised 04/07/2022) revealed .The Director of Nursing will be responsible in assuring that each resident's Medication Review Record is reviewed and follow-up actions to recommendations are documented. 676282 Page 2 of 7 676282 06/15/2023 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #4) of 6 residents reviewed for pharmacy services had a drug regimen that was free from an unnecessary drug, which was administered for an excessive duration. Residents Affected - Some The facility failed to ensure: 1. The pharmacist's Physician Notification Letter dated 03/07/2023 reflected Resident #4 had a routine order for a medication (Robitussin Nighttime DM [Dextromethorphan]) that was not recommended for routine use in the elderly. 2. The pharmacist's Physician Notification Letter dated 05/09/2023 reflected Resident #4 was still receiving the medication routinely as of 6/14/23. The physician signed the 05/09/2023 letter, agreeing to discontinue the routine administration of the medication. 3. The MAR for Resident #4 for March, April, and May 2023 reflected the medication was administered to the resident nightly. 4. The June 2023 MAR for Resident #4 reflected the medication was administered to the resident nightly until 06/13/2023. 5. The surveyor inquired about the medication on 06/14/2023. The routine order was discontinued that day. These failures could place residents at risk for complications resulting from receiving a medication contraindicated for extended routine use. Findings Include: Record review of the admission Record (printed 06/15/2023) revealed Resident #4 was 84-years-old, admitted to the facility on [DATE]. Diagnoses included muscle weakness, asthma (breathing difficulty), insomnia (difficulty sleeping), and chronic respiratory failure (breathing difficulty). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she scored 15/15 on the BIMS, indicative of intact cognition. She required limited assist for bed mobility and transfers. She used a wheelchair for mobility. The MDS reflected Resident #4 received a hypnotic (medication to help sleep) for all seven days of the seven-day look-back period. Record review of Resident #4's Care Plan dated 05/16/2023 read in part . Resident #4 receiving a sedative or hypnotic . Goal: the resident will be free of any discomfort or adverse side effects. Intervention: Administer sedative/hypnotic medications as ordered by the physician . Record review of Resident #4's Medication Regimen Review note dated 03/07/2023 read in part that a Physician Notification Letter was sent on 03/07/2023 . Record review of Resident #4's pharmacy Physician Notification Letter dated 03/07/2023 read in part that Resident #4 was receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at 676282 Page 3 of 7 676282 06/15/2023 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bedtime for cough. The letter reflected .Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula) . Accept/decline' and physician signature areas were blank. Record review of Resident #4's Medication Regimen Review note dated 04/12/2023 read in part Check for response to 3/7/2023 letter to PCP to stop routine Robitussin Nighttime cough. Follow up: change the medication to PRN . Record review of Resident #4's Medication Regimen Review note dated 05/09/2023 read in part . Re-send the letter to discontinue the routine Robitussin Nighttime DM. Nurse Follow-Up: Noted . Record review of Resident #4's pharmacy Physician Notification Letter dated 05/09/2023 read in part . Receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula). Accept/decline' and physician signature areas marked 'accept' and scribed D/C Robitussin Nighttime DM by Nurse Practitioner (05/11/2023) . Record review of Resident #4's MARs dated March. April, and May 2023 revealed the order for routine Robitussin Nighttime Cough DM was in place, and the facility administered the medication nightly for those three months. Record review of Resident #4's Medication Regimen Review note dated 06/13/2023 read in part . Routine Robitussin Nighttime DM medication to be discontinued . Record review of Resident #4's MAR dated June 2023 read in part . Routine Robitussin Nighttime Cough DM . The MAR reflected Resident #4 received the medication every night in June 2023 up to 06/13/23 . Observation and interview on 06/14/2023 at 3:40 p.m., the DON said per the facility protocol for pharmacy reviews, she was responsible for reviewing the Medication Regimen Review notes, then on the following day she gave the Physician Notification Letters to the physician. She said the recommendations were to be implemented within seven days. The Surveyor presented Resident #4's pharmacy review note scribed in nurse's follow-up notes on 4/12/23. The DON said the note scribed in the 04/12/2023 Nurse Follow-Up area for the medication to be changed to PRN was her writing. This Surveyor asked if Resident #4 was still receiving the routine Robitussin medication. The DON pulled up the electronic MAR dated June 2023. She verbally acknowledged Resident #4 was still receiving the routine Robitussin Nighttime Cough DM nightly. Interview on 06/14/2023 at 3:50 p.m., the DON said she had spoken to Resident #4, and the resident wanted to receive the medication every night. When asked if the physician had been informed, the DON said she would notify the physician at this time. Interview on 06/15/2023 at 3:15 p.m., the DON said the Charge Nurse was responsible to update the orders when a pharmacy recommendation was received. She said the order for Resident #4 had just been overlooked. Record review of the facility policy Medication Regimen Review (revised 04/07/2022) revealed .The 676282 Page 4 of 7 676282 06/15/2023 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0757 Director of Nursing will be responsible in assuring that each resident's Medication Review Record is reviewed and follow-up actions to recommendations are documented. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676282 Page 5 of 7 676282 06/15/2023 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 food in accordance with professional standards for food service safety. Residents Affected - Some The facility failed to ensure: -Previously opened frozen foods were not sealed or labeled with the date they were opened. -Previously opened refrigerated foods were not sealed or labelled with the date they were opened. -Non-perishable foods in the pantry were not labelled with the date they were opened. The failure placed residents at risk for food-borne illness associated with improper food storage. Findings include: Findings include: Observation on 06/13/2023 at 8:00 a.m., revealed the facility was part of a campus that included assisted and independent living. All three entities were serviced by the same kitchen. Observation and interview on 06/13/2023 at 8:22 a.m., revealed the DM accompanied the surveyor to tour the kitchen area. Observation of the walk-in freezer revealed an unsealed box of frozen cookies. There was no label to indicate the date it was opened. Observation revealed an open and unsealed box of Beyond Burgers plant-based patties. There was no label to indicate the date it was opened. Observation revealed an opened/resealed box of flat bread. There was no label to indicate the date it was opened. The DM said they do not date the packages when they open them. Observation on 06/13/2023 at 8:25 a.m., of the walk-in refrigerator revealed a five-pound bag of Zesty Peeled Garlic was open on the shelf. It was a resealable bag, but it was not sealed. There was no label to indicate the date it was opened. Observation on 06/13/2023 at 8:29 a.m., revealed the dry pantry contained a previously opened large bag of uncooked ziti. It was sealed with transparent plastic wrap. There was no label to indicate when the bag was opened. The bag was in a box with sealed ziti. Interview on 06/13/2023 at 8:30 a.m., the DM said if the foods were in the original containers, they do not date them because they have a year shelf life. He said they should have dated them. Record review of the facility policy Food Storage Policy (no date) provided by the facility on 06/15/2023 revealed .When item is removed from stock and opened for use and subsequent storage, an open on date should be placed on the package. The United States Public Health Service Food Code, 2013, page 92, reflects 676282 Page 6 of 7 676282 06/15/2023 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . 676282 Page 7 of 7