Health inspection·February 12, 2026

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 Page 1 of 2 676289 676289 02/12/2026 The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 676289 Page 2 of 2