F 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's
ability to function.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure PRN orders for psychotropic drugs
were limited to 14 days for 1 (Resident #64) of 5 residents reviewed for unnecessary medications.The
facility failed to ensure Resident #64's PRN prescription of Ativan (a medication used to treat the symptoms
of anxiety) was discontinued after 14 days. The facility did not document a rationale for the continued
provision of the medication.This failure could place residents at risk for adverse reactions and negative side
effects from the administration of medication and dependence on unnecessary medications. Findings
included:Review of Resident #64's significant change in status MDS assessment dated [DATE] reflected a
[AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses:
neurocognitive disorder with Lewy bodies (a type of progressive brain disease that impairs thinking,
movement, behavior, and mood), psychotic disorder with hallucinations, muscle wasting, and difficulty
walking. She had a BIMS score of 9, indicating moderate cognitive impairment.Review of Resident #64's
comprehensive care plan dated 09/09/2024 reflected The resident uses anti-anxiety medicationfor dx of
anxiety. Interventions included Give anti-anxiety medications ordered by physician. Monitor/document side
effectsand effectiveness. Antianxiety side effects: Drowsiness, lack of energy, Clumsiness, slow reflexes,
Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking
and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision.Record review
of Resident #64's active physician order report dated 02/12/2026 reflected an order for Ativan Oral Tablet
0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/ agitation/ restlessness
dated 01/25/2026.Record review of Resident #64's Medication Administration Record for the month of
February 2026 reflected there had been no administration of Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1
tablet by mouth every 8 hours as needed for anxiety/ agitation/ restlessness.In an interview and observation
on 02/10/2026 at 2:12 p.m. Resident #64 was found to be awake and alert. She stated she was well taken
care of. Resident #64 was talking about the Baptist church when inquiring about her care.In an interview on
02/12/2026 at 11:19 a.m. the ADON stated usually there was a 14 day stop date for all as needed
psychoactive medications. She stated the ADONs run a report daily and review it to observe for current and
discontinued medications to look and correct discrepancies within the orders. She stated she was not sure
why Resident #64 did not have a stop date on her Ativan. It just must have been missed. The ADON stated
a risk for residents for not having a stop date on as needed psychotropics could be over sedation.In an
interview on 02/12/2026 at 11:39 a.m. the DON stated as needed psychotropic meds were to have a 14 day
stop date. If the medication were to be continued the facility would get an extended letter from the
physician. She stated the ADON and DON do order listing reports each morning and if they found a PRN
medication without a stop date, they would contact the doctor and get clarification on the order. The DON
stated risk to the resident for not having stop dates on as needed
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676289
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676289
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Atrium of Bellmead
2401 Development Blvd.
Bellmead, TX 76705
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
psychotropic medications was that the resident could continue to get medication used when it is not
necessarily needed.Record review of facility policy titled Psychotropic Medication dated 2/12/2025 reflected
Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary
to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for
antidepressant, hypnotic, and antianxiety drugs are limited to 14 days. Except 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 the rational in the resident's medical record and indicate the duration for the PRN
order. 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.
Event ID:
Facility ID:
676289
If continuation sheet
Page 2 of 2