Every finding on record at The Royal Home

Based on interview and record review the facility failed to schedule a Registered Nurse for at least 8 consecutive hours a day for April, May, and June of 2025.This failure had the potential to affect all residents in the facility by limiting access to professional nursing assessments, care and supervision of staff which could place the residents at risk for unmet medical needs, delayed response to emergencies and treatment, and poor quality of care. During a review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report from [name of oversight agency], the FY Quarter 3 2025 (April 1 - June 30) report indicated that the facility had no Registered Nurse (RN) onsite on the following dates: A. APRIL 2025 - 04/06, 04/11, 04/13 - 3 Days B. MAY 2025- 05/19, 05/20, 05/21, 05/22, 05/23, 05/26, 05/27, 05/28, 05/29, 05/30 - 10 Days C. JUNE 2025- 06/02, 06/03, 06/04, 06/05, 06/06, 06/09, 06/10, 06/11, 06/12, 06/13, 06/16, 06/17, 06/18, 06/19, 06/20, 06/23, 06/24, 06/25, 06/26, 06/27, 06/30 - 21 DaysDuring an interview with the Assistant Administrator (A-ADM), on 09/24/2025 at 4:32 PM, the A-ADM stated they had issues with hiring a regular RN to come work during the months of April, May and June 2025. The A-ADM also stated that they had one RN during that time, but the RN could not cover all the days. The A-ADM further stated the facility had difficulty recruiting full time RN or Director of Nursing (DON) and could not cover RN shift due to fast turnover and frequent resignations. The A-ADM also stated that they sometimes had to rely on Licensed Vocational Nurse (LVN) to cover the building. The A-ADM confirmed that they do not have a waiver for RN.During an interview with the LVN on 09/24/2025 at 5:45 PM, the LVN stated that it is important to have an RN in the building to assess and provide treatment to residents accurately. During a review of the facility's reported Census and Direct Care Service Hours Per Patient Day (DHPPD), and Direct Care Timecard Report, the following dates on Actual Total Care Services Hours showed no RN worked at the facility: 1. 04/06/2025 - 72.92 - No RN Hours recorded2. 04/11/2025 - 72.50 - No RN Hours recorded3. 04/13/2025 - 71.75 - No RN Hours recorded4. 05/19/2025 - 72.60 - No RN Hours recorded5. 05/20/2025 - 72.28 - No RN Hours recorded6. 05/21/2025 - 74.88 - No RN Hours recorded7. 05/22/2025 - 72.23 - No RN Hours recorded8. 05/23/2025 - 72.50 - No RN Hours recorded9. 05/26/2025 - 72.27 - No RN Hours recorded10. 05/27/2025 - 72.32 - No RN Hours recorded11. 05/28/2025 - 72.30 - No RN Hours recorded12. 05/29/2025 - 72.18 - No RN Hours recorded13. 05/30/2025 - 72.72 - No RN Hours recorded14. 06/02/2025 - 72.75 - No RN Hours recorded15. 06/03/2025 - 73.40 - No RN Hours recorded16. 06/04/2025 - 75.43 - No RN Hours recorded17. 06/05/2025 - 72.27 - No RN Hours recorded18. 06/06/2025 - 72.40 - No RN Hours recorded19. 06/09/2025 - 72.33 - No RN Hours recorded20. 06/10/2025 - 73.10 - No RN Hours recorded21. 06/11/2025 - 74.35 - No RN Hours recorded22. 06/12/2025 - 73.05 - No RN Hours recorded23. 06/13/2025 - 72.30 - No RN Hours recorded24. 06/16/2025 - 72.10 - No RN Hours recorded25. 06/17/2025 - 72.22 - No RN Hours recorded26. 06/18/2025 - 73.78 - No RN Hours recorded27. 06/19/2025 - 72.72 - No RN Hours recorded28. 06/20/2025 - 72.37 - No RN Hours recorded29. 06/23/2025 - 72.23 - No RN Hours recorded30. 06/24/2025 - 72.37 - No RN Hours recorded31. 06/25/2025 - 73.08 - No RN Hours recorded32. 06/26/2025 - 72.37 - No RN Hours recorded33. 06/27/2025 - 72.87 - No RN Hours recorded34. 06/30/2025 - 72.15 - No RN Hours recorded During a concurrent interview and record review with the A-ADM on 09/25/2025, at 11:15 AM, the facility's undated policy and procedure (P&P) titled Careers: Director Of Nursing was reviewed. The P&P indicated, .Management and Leadership.Plans, organizes, direct and controls nursing services.makes use of management practices that include empowerment of staff, the provision of clear and concise expectations regarding duties assigned employees. Careers: Registered Nurse. indicated, .Assessment.Observes, records and reports client social, medical and psychiatric behavior. The A-ADM confirmed having a full time RN in the facility is important for residents' safety and to ensure quality of care.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene in between assisting Residents 7 and 18 with the feeding.2. Uncovered soiled linen was placed in the clean area of the laundry room. These failures had the potential for cross contamination and spread of infection which can adversely affect the health and wellbeing of 19 residents, staff, and visitors.1. During dining observation, on 9/23/25, at 11:56 AM, Certified Nursing Assistant (CNA) 2 was noted assisting Residents 7 and 18 simultaneously, who were seated across from each other at the same table. CNA 2 did not perform hand hygiene in between assisting Residents 7 and 18 with the feeding. During an interview with CNA 2, on 9/23/25, at 12:28 PM, CNA 2 stated that handwashing between assisting residents was important to prevent cross contamination. During an interview with the Director of Nursing (DON), on 9/25/25, at 9:04 AM, the DON verified the importance of handwashing in between resident care to prevent the spread of infection. During an interview with the Director of Staff Development / Infection Preventionist (DSD/IP), on 9/25/25, at 3:12 PM, the DSD/IP confirmed the importance of hand hygiene to break the chain of infection. A review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Dementia (loss of mental function such as thinking, memory, and reasoning skills) and Schizophrenia (a severe brain disorder in which people interpret reality abnormally). A review of Resident 18's Face Sheet indicated that resident was admitted to the facility on [DATE], with diagnoses which included Depression (a mental health condition characterized by persistent feelings of sadness) and Anemia (a condition of having low levels of healthy red blood cells). A review of the facility's undated policies and procedures titled, Infection Control Policy, indicated, .4. STANDARD PRECAUTIONS. Staff must observe standard precautions at all times, including: Hand Hygiene: Wash hands with soap and water or use alcohol-based sanitizer before and after resident contact. 2. During a tour of the laundry area with the Director of Staff Development / Infection Preventionist (DSD/IP), on 9/24/25, at 11:46 AM, an uncovered hamper containing linens beneath the clean area countertop was observed. Certified Nursing Assistant (CNA) 1 verified that the hamper contained soiled fitted sheets and flat sheets. During an interview with the DSD/IP, on 9/24/25, at 11:51 AM, the DSD/IP confirmed that dirty linens should not be placed in the clean area of the laundry room to break the chain of infection. During an interview with the Director of Nursing (DON), on 9/25/25, at 10:01 AM, the DON stated that the laundry room should separate the dirty linens from the clean area to prevent the spread of infection. A review of facility's undated policy titled, INFECTION CONTROL IN LINEN HANDLING, indicated, . 4. Soiled linen hampers should always be kept covered and linen neatly inside. This only prevents spread of infection but also helps to control odors.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when there were six opened and unlabeled food packages and bottles found inside the kitchen's refrigerator, freezer, and tray condiments area.This failure had the potential to cause foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) to 19 of 19 medically compromised residents who receive food served by the kitchen.During an initial observation tour of the kitchen and interview with Dietary Kitchen Supervisor (DKS), on 09/23/2025, at 8:25 AM, the DKS inspected the kitchen condiments area, refrigerators, and freezer, and found the following food items: I. One gallon of soy sauce half empty, opened, undated II. One gallon of cooking oil half empty, opened, undated III. Two half gallons of milk more than half empty, opened, undatedIV. One bag of frozen cauliflower, undatedV. One bag of frozen mixed vegetables, undatedVI. One bag of frozen green beans, undatedDuring a phone interview with the Registered Dietitian (RD), on 09/24/2025 at 11:27 AM, the RD stated opened and undated food packages should be thrown away since they do not know when it was opened. The RD also stated the expectation is the dietary staff should follow infection control precautions for food safety.During an interview and record review with the DKS on 09/24/2025, at 3:38 PM, the DKS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, Labeling and dating of Foods, was reviewed. The P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered to facility needs to be marked with a delivery or received date.Newly opened food items will be needed to be closed and labeled with an open date and used by the date that follows the various storage guidelines. The DKS confirmed the finding and stated the policy should have been followed.A review of the FDA Federal Food Code 2022, 3-101.11 titled Safe, Unadulterated, and Honestly Presented.Labeling-General, indicated, .Sources of packaged food must be labeled in accordance with law. Proper labeling of foods allows consumers to make informed decisions about what they eat. Many consumers, as a result of an existing medical condition, may be sensitive to specific foods or food ingredients .

Based on interview and record review the facility failed to designate a qualified Director of Food Services to provide the daily oversight of the dietary department which includes implementing menus, purchasing food, training staff, and ensuring compliance with all state and federal regulations.This failure had the potential to result in a lack of oversight into the operations of the dietary department and supervision of staff, which could lead to poor quality of services in the department which could affect residents' health and wellbeing.During an interview with the Dietary Kitchen Supervisor (DKS) on 09/24/2025, at 10:35 AM, the DKS stated she is the Director of Food Services and runs the day-to-day operations of the kitchen. The DKS stated she is not a certified dietary manager because she failed to complete her school two years ago due to personal reasons but attended online training about food protection and management in 2023. The DKS also stated she had no bachelor's degree in food and nutrition and had not completed an approved dietary service training program as required by regulation.During an interview with Kitchen Aide (KA) on 09/24/2025, at 10:41 AM, the KA stated she directly reports to the DKS. The KA further stated that the DKS supervises the kitchen, creates kitchen schedules and assignments, and trains them on how to prepare and serve food and how to keep the kitchen clean.During a telephone interview with the Registered Dietitian (RD), on 09/24/2025, at 11:21 AM, the RD stated she comes to the facility once a month and quarterly to evaluate resident menus and diets, residents who are newly admitted , and residents that staff referred for consultation. The RD stated she was not sure if the DKS is licensed or met the qualifications required to manage the kitchen.During an interview with the Assistant Administrator (A-ADM) on 09/25/2025, at 9:28 AM, the A-ADM stated they used to have a licensed DKS, but when she left in 2022, their current DKS, who was the former Assistant Dietary Kitchen Supervisor (A-DKS), assumed the position.During an interview and record review with the A-ADM on 09/25/2025, at 9:45 AM, the facility's undated policy and procedure titled Job Description: Position: FNS Director was reviewed. The P&P indicated, Qualifications.3. Must meet the qualifications of a FNS Director as stated under State & Federal regulations. The A-ADM confirmed and acknowledged that the current DKS did not meet the state qualifications for a dietary supervisor.

Based on interview and record review, the facility failed to ensure Physician Orders for Life Sustaining Treatment (POLST - form that documents an individual's preferences for end-of-life care ) were completed for four of nine sampled residents (Residents 1, 4, 12, and 19).This failure had the potential for residents receiving unnecessary treatment in the event of an emergency.1. A review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Schizophrenia (a severe brain disorder in which people interpret reality abnormally) and Type II Diabetes Mellitus (a long term condition that causes high blood sugar levels).A review of Resident 1's POLST form indicated that Section D (Information and Signatures) included the physician's signature without a date and was missing the patient or legal decision-maker's signature.2. A review of Resident 4's Face Sheet indicated that resident was admitted to the facility on [DATE], with diagnoses which included Dementia (loss of mental function such as thinking, memory, and reasoning skills) and Chronic Venous Insufficiency (a condition where the veins in the legs do not work properly leading to blood pooling).A review of Resident 4's POLST form indicated that Section D (Information and Signatures) included the physician's signature but missing the patient or legal decision-maker's signature.3. A review of Resident 12's MDS - Minimum Data Set (a standardized assessment tool) indicated that resident was admitted to the facility on [DATE], with diagnoses which included Neurogenic Bladder (a condition where nerve damage prevents the brain and urinary bladder from communicating properly leading to a loss of bladder control).A review of Resident 12's POLST form indicated that Section D (Information and Signatures) included the physician's signature without a date and was missing the patient or legal decision-maker's signature.4. A review of Resident 19's Face Sheet indicated that resident was admitted to the facility on [DATE], with diagnoses which included Schizophrenia (a severe brain disorder in which people interpret reality abnormally) and Hyperthyroidism (a condition where the thyroid gland produces more thyroid hormones).A review of Resident 19's POLST form indicated that Section D (Information and Signatures) included the physician's signature but missing the patient or legal decision-maker's signature.During an interview with the Director of Nursing (DON) and Social Services Director (SSD), on [DATE], at 9:18 AM, the DON and SSD confirmed the importance of timely signing and completing the POLST to ensure accurate care for residents in the event of an emergency.A review of facility's undated policies and procedures titled, Policy Procedure: POLST (Physician Orders for Life-Sustaining Treatment), indicated, 1.POLICY STATEMENT. The POLST form is a legally recognized medical order in California that communicates a resident's wishes regarding cardiopulmonary resuscitation (CPR), medical interventions, artificial nutrition, and other end-of-life care preferences. 4. PROCEDURE. Who May Complete: The POLST form must be completed by a licensed healthcare provider (physician, nurse practitioner, or physician assistant) in discussion with the resident or their representative.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet the needs of one of 19 residents (Resident 8) when resident's lunch on 09/23/2025 had visible chunks of food. This failure had the potential to result in Resident 8 choking during meals. During an observation on 09/23/2025, at 12:20 AM, in the dining room, Resident 8's tray consisted of chicken barbeque, seasoned potato and corn with notable lumps present. Resident 8's diet ticket stated fortified puree. During an interview with the Dietary Kitchen Supervisor (DKS) in the kitchen, on 09/23/2025, at 2:40 PM, the DKS stated that Resident 8's diet order is puree. The DKS further stated that the meal should have had a smooth texture with no lumps. During a review of the Physician Orders for Resident 8, the diet order indicated a Fortified Pureed Texture with Thin Liquids.During a telephone interview and record review with the Registered Dietitian (RD) on 09/24/2025, at 11:23 AM, the RD notes titled, Nutritional Quarterly Review indicated that Resident 8 has swallowing difficulty and has an order of fortified pureed texture diet. The RD stated the expectation for a puree diet is to have no lumps and to be smooth like pudding for safety swallowing. The RD further stated the diet order should have been followed.During an interview and record review with the facility Assistant Administrator (A-ADM) on 09/25/2025, at 9:20 AM, the facility's policy and procedure (P&P) titled, Section 3 Menu Planning, dated 2023 was reviewed. The P&P indicated, 1. The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility.4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances. The facility A-ADM stated the facility staff should have followed the P&P.

Based on observation, interview, and record review, the facility failed to promote independence and dignity to two of two residents (Resident 7 & 18) when Certified Nursing Assistant (CNA) 2 was standing and not seated at eye level while assisting both residents with feeding. This failure had the potential to cause residents to feel disrespected, undignified, as well as experience psychological discomfort.During dining observation on 9/23/25 at 11:56 AM, Certified Nursing Assistant (CNA) 2 was observed assisting Residents 7 and 18 simultaneously as they were seated across from each other at the same table. CNA 2 was standing while helping Residents 7 and 18 with their meals.During an interview with CNA 2, on 9/23/25, at 12:28 PM, CNA 2 stated that residents might not finish their meals when assisted in a sitting position. During an interview with the Director of Nursing (DON), on 9/25/25, at 9:04 AM, the DON stated that staff were expected to be at eye level with residents when rendering care. During an interview with the Director of Staff Development / Infection Preventionist (DSD/IP), on 9/25/25, at 3:12 PM, the DSD/IP confirmed the importance of feeding residents at eye level. The DSD/IP stated, You don't need to show to residents that you're above them. A review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Dementia (loss of mental function such as thinking, memory, and reasoning skills) and Schizophrenia (a severe brain disorder in which people interpret reality abnormally). A review of Resident 18's Face Sheet indicated that resident was admitted to the facility on [DATE], with diagnoses which included Depression (a mental health condition characterized by persistent feelings of sadness) and Anemia (a condition of having low levels of healthy red blood cells). A review of facility's undated policies and procedures titled, Feeding Assistance Policy and Procedure, indicated, Policy Purpose: To ensure Certified Nursing Assistant (CNA) provide safe, respectful, and dignified feeding assistance to residents, minimizing the risk of aspiration, choking, or other complications, and promoting resident autonomy and well-being. CNA Positioning During Feeding: CNA should be seated at eye level with the resident when possible.

Based on observation, interview and record review, the facility failed to ensure two of five resident rooms accommodated no more than four residents.This failure could compromise patient privacy resulting to resident distress, anxiety, and embarrassment.During an initial tour, on 9/23/25, at 9:28 AM, it was observed that room [ROOM NUMBER] was occupied by five residents, and room [ROOM NUMBER] had eight residents. Noted both rooms had mobile privacy screens in between beds. All residents in both rooms were ambulatory.room [ROOM NUMBER] accommodated five residents (Residents 2, 4, 11, 13, and 14). room [ROOM NUMBER] accommodated eight residents (Residents 1, 5, 7, 12, 15, 16, 17, and 19).During an interview with the Director of Staff and Development / Infection Preventionist (DSD/IP), on 9/24/25, at 5:48 PM, the DSD/IP stated that facility had room waivers but not able to provide a copy of the approved room waiverDuring an interview with the Administrator (ADM), on 9/25/25, at 11:28 AM, the ADM stated that the facility lost the copy of the approved room waivers.The facility was not able to provide a copy of the approved room variance waivers.

Based on observation, interview and record review, the facility failed to meet the minimum requirement of 80 square feet per resident for three of five resident rooms.This failure had the potential to limit the freedom of movement of the residents that occupied these rooms, which may place them at risk for injury.During an initial tour, on 9/23/25, at 9:28 AM, it was observed that rooms [ROOM NUMBER] had limited space to accommodate the number of residents occupying these rooms. room [ROOM NUMBER] was occupied by three residents, room [ROOM NUMBER] had five residents, and room [ROOM NUMBER] had eight residents. All residents in three rooms were ambulatory. During an interview with the Director of Staff and Development / Infection Preventionist (DSD/IP), on 9/24/25, at 5:48 PM, the DSD/IP stated that facility had room waivers but not able to provide a copy of the approved room waivers. The DSD/IP provided a copy of the facility letter requesting the renewal of room waivers, addressed to the Department, dated 9/24/25.A review of the letter requesting the renewal of room waivers, dated 9/24/25, indicated the following room measurements:a. room [ROOM NUMBER] measured 238 square feet and housed three residents. The allocated space for each resident was 79.33 square feet.b. room [ROOM NUMBER] measured 352.63 square feet and housed five residents. The allocated space for each resident was 70.52 square feet.c. room [ROOM NUMBER] measured 631.95 square feet and housed eight residents. The allocated space for each resident was 78.99 square feet.During an interview with the Administrator (ADM), on 9/25/25, at 11:28 AM, the ADM stated that the facility lost the copy of the approved room waivers. The facility was not able to provide a copy of the approved room variance waivers.

Based on observation and interview, the facility failed to develop a water management program with measures to assess, prevent, and monitor the facility's water systems for the presence of Legionella (a bacteria that colonizes pipes and other water systems that can cause a serious pneumonia called Legionnaire's Disease) and other opportunistic waterborne pathogens. As a result, all departments and all 19 residents who used the facility's water were potentially put at risk for contracting Legionnaire's Disease and/or other waterborne illnesses. Findings: According to the Centers for Medicare and Medicaid Services (CMS) Quality, Safety, Oversight group (QSO) QSO 17-30 (a federal document guiding practice in nursing homes) revised 7/6/18, .Subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease (LD) . CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread . develops and implements a water management program [adhering to professional standards] . specifies testing protocols and acceptable ranges for control measures, and document the results . Healthcare facilities are expected to comply with CMS requirements . Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance A review of the facilty's Disaster Manual Policies and Procedures review date 6/14/23, did not include any water management and/or Legionella plans. On 12/12/23 at 10:41 A.M., an interview was conducted with the facility's administrator (ADM). The ADM stated the facility's water should be fine as it came from the county and the county was responsible for testing and ensuring its quality. The ADM stated the facility did not have a water management system in place and was unaware there was a requirement. On 12/13/23 at 11:05 A.M., an interview was conducted with the facility's IPN. The IPN stated the facility did not have a process or system to assess, monitor, and prevent the growth of Legionella and other waterborne pathogens in its water systems. The IPN stated there was no policy to guide the facility's water management practice. On 12/13/23 at 4 P.M., an observation of the facility indicated there were four resident/staff bathrooms with a total of four sinks, three shower heads, and four toilets. The facility was also observed to have one laundry room sink, one washing machine, one water heater, one sink in the nurses' station, one sink in the kitchen, and outside hoses and faucets. On 12/14/23 at 8:21 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility should have a process to assess, monitor, and prevent the growth of Legionella and other waterborne pathogens in its water systems. The DON stated a water management system should be in place to ensure the water supply available to residents and staff was free of opportunistic pathogens.

Based on observation, interview, and record review, the facility's Quality Assurance Performance Improvement program (QAPI - a data driven and proactive approach to quality improvement) failed to identify areas of improvement related to: 1. Developing a water management program (see F-880). 2. Competency of kitchen staff (see F-802). 3. Kitchen sanitation (see F-812). These failures had the potential to affect the health and safety of the facility staff and 19 of 19 residents. Findings: On 12/15/23 at 10:10 A.M., an interview was conducted with the administrator (ADM), the director of nursing (DON), and the administrative assistant. The ADM stated the QAPI committee did not review and discuss the Centers for Medicare and Medicaid Services (CMS) Quality, Safety, Oversight group (QSO) letters unless they were pertinent enough and related to resident care and safety. The ADM stated since having a water management program was a requirement in the State Operations Manual and on QSO letters, it should have been discussed and identified as an area of improvement by the facility's QAPI and a water management program, policy, and procedure, should have been developed. The ADM stated kitchen audits conducted by the registered dietitian were presented during the quarterly QAPI meetings. The ADM stated he had been unaware of any issues in the kitchen. The ADM stated kitchen competency should have been assessed for DA 11 and all kitchen staff. A review of the facility's undated policy titled Policy and Procedure: QAPI, indicated, .It is the policy of [facility name] to continually improve the well-being of our residents . Through QAPI, we focus on particular issues that could benefit from a sharper focus . Then we make a goal for the facility to improve this particular problem

Based on observation, interview, and record review, the facility did not maintain sanitary conditions for food safety in the kitchen according to Federal Food and Drug Administration's standards of practice when: 1. Food was not dated and stored properly in two of two refrigerators; 2. A hairnet was not worn properly by one of two kitchen staff (DA 11); 3. Handwashing was not performed by one of two kitchen staff (DA 11), when entering the kitchen to perform kitchen duties; and 4. One of two sanitation red buckets was not prepared properly for cleaning and disinfecting. As a result, there was the potential to spread food borne illnesses to 19 residents. Findings: 1. On 12/12/23 at 7:35 A.M., an initial tour was conducted with CK 11 of the refrigerator within the kitchen. a. Cut celery sticks were inside a clear plastic zip bag, with no date labeled. b. An opened package of hotdog's was inside a clear unsealed plastic bag, with no date labeled and juice leaked out when picked up. c. Slices of white cheese (approximately 15 slices) were wrapped within cellophane wrap, with no date labeled. At 7:39 A.M., an interview was conducted wit CK 11. CK 11 stated all the undated items needed to be thrown away because there was no date of how long they have been in the refrigerator and the packaged hotdog's were not properly sealed. On 12/12/23 at 7:42 A.M. an initial tour was conducted with CK 11 of the refrigerator within in the dry storage room. d. Shredded cheese was placed in multiple clear zip bags with no date labeled. There were three small bags of shredded white cheese and five bags of shredded orange cheese. e. A head of romaine lettuce was in a clear plastic bag with no date labeled. At 7:49 A.M., an interview was conducted with CK 11. CK 11 stated the cheese was delivered on 12/8/23, and was broken down to smaller bags, which should have been dated and labeled at that time. CK 11 stated all produce needed to be dated when removed from its original packaging. 2. On 12/12/23 at 12:02 P.M., an observation outside the kitchen was conducted of the kitchen staff during the initial resident dining room observation task. DA 11 was inside the kitchen, wearing a hairnet, which partially covered the back of her head. The hairnet came to the middle of her back scalp, and 4-5 inches of straight dark hair was hanging down, to her neck, uncovered and not contained. On 12/12/23 at 2:44 P.M., an interview was conducted with DA 11. DA 11 stated she was usually the housekeeper, but was asked to help out in the kitchen his week, since the regular DA, was on vacation. DA 11 stated she did received training on kitchen duties, but she was not aware her hair had to be completely covered within the hairnet. DA 11 stated the hairnet was probably necessary, to prevent hair from falling into the resident's food. On 12/13/23 at 9:04 A.M., an interview was conducted with the RD. The RD stated labeling, dating and securing food stored in the refrigerator was important to ensure the food was safe for consumption. The RD stated if the food was not dated or sealed, it needed to be thrown away. The RD stated undated and unsealed food could lead to residents getting sick or having gastrointestinal upset. The RD stated all head and facial hair needed to be covered and contained for anyone entering the kitchen. The RD stated hair could fall out and contaminate the food, counters, and dinnerware. 3. On 12/13/23 at 11:49 A.M., an observation was conducted of the DA 11, during the lunch tray line observation. DA 11 entered the kitchen and did not perform handwashing. DA 11 was observed removing and organizing plates, bowls and serving utensils. At 11:52 A.M., DA 11 was reminded to perform hand hygiene when entering the kitchen and she stated, I didn't know I needed to. 4. On 12/14/23 at 07:54 A.M., CK 11 was asked to perform a chemical test strip on the red solution disinfectant bucket after she was seen wiping down the surface tops following breakfast. The chemical test strip did not register. CK 11 stated the test strip should register 50-100 parts per million (ppm), indicating the disinfectant solution was appropriate for sanitizing the surfaces. On 12/14/23 at 7:57 A.M., CK 11 asked DA 11, how many pumps of the disinfectant she added to the water in the red bucket. DA 11 stated she was, not aware she was supposed to measure the chemicals when adding it to water. CK 11 stated without the proper disinfectant added, surfaces were not being properly cleaned and sanitized, which could lead to residents getting sick. On 12/14/23 at 8:02 A.M., an interview and record reviewed was conducted with CK 11 of DA 11's training. CK 11 stated DA 11 has never worked in the kitchen until this week and was considered the emergency back-up assistant. CK 11 reviewed DA 11's kitchen training, which consisted of a video and then a written test. CK 11 produced the written test which was dated 9/30/22. CK 11 stated she was unaware if DA 11 had any additional training since 9/30/22. CK 11 stated she had not trained DA 11 on the importance of red solution buckets and chemical testing, and she should have. CK 11 stated she had never performed any observations of DA 11 to ensure she safely and properly performed any kitchen tasks. On 12/14/23 at 9:22 A.M., a follow-up interview was conducted with the RD. The RD was informed of DA 11 not washing her hands when entering the kitchen and not knowing the importance of preparing a red soluntion bucket. The RD she was unaware DA 11 had never worked in the kitchen before and expected all kitchen staff to have training and competency. The RD stated CK 11 was responsible for training the kitchen staff. The RD stated she was a contracted employee and only came to the facility on ce a month, which included a quick walk through of the kitchen, discussing issues with CK 11, asking if there were any issues, and then reviewing menus, resident charts, and meeting with the residents. The RD further stated her last kitchen audit was August 2023, which identified food not being labeled and dated. The RD stated with food not being dated, hair not contained in a hair nets, handwashing not being performed, and red sanitation buckets bucket not testing properly, could lead to cross contamination for the residents when food was ingested. On 12/15/23 10:05 A.M., an interview was conducted with the ADM. The ADM states DA 11 was the facility's emergency back-up person for dietary assistance. The ADM stated he was unaware if this week was DA 11's first time in the kitchen or not. The ADM stated he expected CK 11 to be training staff and for the RD to oversee the training. The ADM stated he received the RD's kitchen audits every quarter, when the QA (Quality Assurance) committee met. The ADM was unaware there were current kitchen issues with DA 11's performance and competencies. According to the facility's policy titled Refrigerated Left-over Storage, undated, .2. Date .8. All food stuffs [sic] are to be dated . According to the facility's policy, titled Food Preparation, undated, All food employees preparing, serving, or handling food or utensils shall wear hair restraints, such as hats, hair coverings, or nets which are designed and worn to effectively keep hair from contacting non-prepackaged food. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 2-301.12, Cleaning Procedure (B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water; (2) Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; P (3) Rub together vigorously for at least 10 to 15 seconds According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 4-601.11, Equipment .Food-contact surfaces (C ) .food-contact surfaces shall be effectively washed to remove or completely loosen soils by using .manual .means necessary such as the application of detergents .rinsed .and sanitized after cleaning .; Inability to effectively wash, rinse, and sanitize the surfaces of food equipment and food contact surfaces may lead to buildup of pathogenic organisms transmissible through food .

Based on observation, interview, and document review, the facility did not ensure food and nutrition service staff were able to competently carry out their job duties when: 1. DA 11 did not contain all her hair within a hairnet; 2. DA 11 did not wash her hands upon entering the kitchen; 3. DA 11 did not know how to prepare a red bucket for sanitation purposes. As a result, this could have led to foodborne illness to all 19 residents at the facility. (Cross Reference F-812) Findings: 1. On 12/12/23 at 12:02 P.M., an observation outside the kitchen area of the kitchen staff was conducted, during the initial resident dining room observation. DA 11 was inside the kitchen, wearing a hairnet, which partially covered the back of her head. The hairnet came to the middle of her back scalp, and 4-5 inches of straight dark hair was hanging down, to her neck, uncovered and uncontained. On 12/12/23 at 2:44 P.M., an interview was conducted with DA 11. DA 11 stated she was usually the housekeeper, but was asked to help out in the kitchen his week since the regular DA was on vacation. DA 11 stated she did received training on kitchen duties, but she was not aware her hair had to be completely covered with the hairnet. DA 11 stated the hairnet was probably necessary to prevent hair from falling into the food. 2. On 12/13/23 at 11:49 A.M., an observation was conducted of DA 11, during the lunch tray line observation. DA 11 entered the kitchen and did not perform handwashing. DA 11 was observed removing plates, bowls and serving utensils. At 11:52 A.M., DA was reminded to perform hand hygiene when entering the kitchen and she stated, I did not know I needed to. 3. On 12/14/23 at 07:54 A.M., CK 11 was asked to perform a chemical test strip on the solution in the red disinfectant bucket after she was seen wiping down the surface tops following breakfast. The chemical test strip did not register. CK 11 stated the test strip should register 50-100 parts per million (ppm), indicating the disinfectant solution was appropriate for sanitizing surfaces. On 12/14/23 at 7:57 A.M., CK 11 asked DA 11, how many pumps of the disinfectant she added to the water in the red bucket. DA 11 stated she was unaware she was supposed to measure the chemicals when adding it to water. CK 11 stated without the proper disinfectant added, surfaces were not being properly cleaned and sanitized, which could lead to residents getting sick. On 2/14/23 at 8:02 A.M., an interview and record reviewed was conducted with CK 11 of DA 11's training. CK 11 stated DA 11 had never worked in the kitchen until this week and was considered the emergency back-up DA. CK 11 provide a 30 question kitchen test, DA 11 took on 9/30/22. CK 11 stated DA 11 watched a video first and then was provided the test to make sure she understood the training. CK 11 stated she was unaware if DA 11 had any training since 9/30/22. CK 11 stated she had not trained DA 11 on the importance of red buckets and chemical testing, and she should have. CK 11 stated she had never performed any observations of DA 11 to ensure she safely and properly performed any kitchen tasks. On 2/14/23 at 9:22 A.M., an interview was conducted with the RD. The RD was informed of DA 11 not washing her hands when entering the kitchen and not knowing the importance of preparing a red bucket solution. The RD she was unaware DA 11 had never worked in the kitchen before and expected all kitchen staff to have training and competency. The RD stated to her knowledge, CK 11 preformed all the training to kitchen staff. The RD stated she was a contracted employee and came to the facility on ce a month, which included a quick walk through of the kitchen, discussing issues with CK 11, asking if there were any issues, and then reviewing resident charts, and meeting with the residents. The RD continued, stating she was aware CK 11 did not have consistent help with DAs. The RD stated she did not provide training to the DAs, and was never asked to. The RD stated she identified food storage issues in the last two kitchen audits. The RD stated the very last audit was conducted in August 2023. The RD stated if kitchen staff were not trained properly it could lead to cross contamination for the residents when food was ingested. On 12/15/23 10:05 A.M., an interview was conducted with the ADM. The ADM states DA 11 was the facility's emergency back-up person for dietary assistance. The ADM stated he was unaware if this week was DA 11's first time in the kitchen or not. The ADM stated he expected CK 11 to be training staff and for the RD to oversee the training. The ADM stated he received the RD's kitchen audits every quarter, when the QA (Quality Assurance) committee met. The ADM was unaware there were current kitchen issues with DA 11's performance and competencies. According to DA 11's competency test, dated 9/30/22, four mutilple chose questions of 30 were marked incorrect. The four questions were related to best handwashing practices, how germs ae commonly spread, proper handwashing techniques, and sanitizing surfaces. According to the facility's job description for Dietary Manager, undated, .1. The Dietary Manager will schedule and supervise the dietary staff and provide in-services training when necessary. Assure all dietary staff are oriented per policy form . According to the facility's job description for Dietary Assistant, undated, .Performs designated work and cleaning routines for the dietary Department.

Based on observation, interview, and record review, the facility failed to ensure three of six residents (3, 5, 14) were free from unnecessary psychotropic medications (drugs that affect the way a person thinks, feels, or acts) when, 1. Resident 14 was administered olanzapine (a psychotropic medication used to treat mental illness) without a clear indication for use, had contradictive monitoring for its use, and did not have an active diagnosis documented related to the necessity for use of olanzapine. 2. Resident 3's behavior monitoring for quetiapine (a psychotropic medication) was unclear. 3. Resident 5 was administered Trazadone (a psychotropic medication) for sleep, a non-FDA approved indication for use, without documented evidence of having the cause of the resident's inability to sleep reviewed and non-pharmacological interventions attempted first. As a result, there was the potential for residents to receive unnecessary psychotropic medications which could cause harm or serious side effects. Findings: 1. A review of Resident 14's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include traumatic brain injury and organic brain disease. A review of Resident 14's Physician's Orders dated 4/30/21, indicated olanzapine 2.5 mg (milligrams) take half a tablet PO (by mouth) every other day. Resident 14's Physician's Orders dated 4/4/23, further indicated, Monitor episodes of agitation AEB [as evidenced by] refusing PO -[olanzapine] every shift. A review of Resident 14's Psychotropic Medication assessment dated [DATE] and 10/1/23, indicated there were zero episodes of refusing to take olanzapine observed in June, July, August, September, October, and November 2023. On 12/13/23 at 7:20 A.M., a joint interview and record review was conducted with licensed nurse (LN) 1. LN 1 reviewed Resident 14's physician orders dated 4/30/21 for olanzapine. LN 1 stated the physician's order should have clearly indicated what the medication was treating. LN 1 stated, I don't know why [Resident 14's] taking it. LN 1 reviewed Resident 14's clinical record and stated the resident did not have a psychiatric diagnosis (mental illness) but had a brain injury. LN 1 reviewed Resident 14's physician's order dated 4/4/23 for monitoring the resident's agitation AEB refusing olanzapine. LN 1 stated to take olanzapine for agitation when refusing to take olanzapine doesn't make sense. On 12/13/23 at 8 A.M., an interview was conducted with Resident 14. Resident 14 stated he only took one medication aside from vitamins and eye drops. Resident 14 stated he took olanzapine, half a pill, every other day. Resident 14 stated he did not know why he had to take olanzapine and that he would ask staff why and did not get an answer. Resident 14 stated years ago someone told him they thought he had schizophrenia (a mental illness). On 12/13/23 at 8:40 A.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 14's clinical record and stated he was not sure why the resident was taking olanzapine. The DON stated the physician's order did not have a clear indication for the use of olanzapine. The DON stated it should be clearly understood why Resident 14 was taking olanzapine, or there could be the potential the resident was receiving an unnecessary medication which could cause harm. The DON further stated there was no documentation of an appropriate diagnosis for the administration of olanzapine in the resident's active clinical chart. The DON stated Resident 14's behavior monitoring for agitation AEB refusing to take olanzapine doesn't make sense and circles around. The DON stated it was not acceptable to give olanzapine for refusing olanzapine and that the resident's order needed clarification. On 12/14/3 at 2:20 P.M., a telephone interview was conducted with the facility's pharmacy consultant (PC). The PC stated the indication for the use of a psychotropic medication should be clearly understood in the order and the diagnosis for the medication and behavior monitoring should be appropriate. The PC stated Resident 14's order for olanzapine needed to be clarified. 2. A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include depression (a mood disorder that causes persistent feelings of sadness), recurrent psychotic features (disconnection from reality), bipolar affective disorder (disorder characterized by extreme mood swings), schizoaffective disorder (mental illness that includes schizophrenia and mood disorder). A review of Resident 3's physician's orders dated 9/17/18, indicated quetiapine 600 mg by mouth at bedtime for schizoaffective disorder AEB repetitively asking people questions and aggressive behavior (i.e. threatening others). The physician's orders also indicated the resident was to be monitored for these behaviors every shift. A review of Resident 3's Psychotropic Medication assessment dated [DATE], indicated quetiapine related behavior .Repetitively question . was observed 153 times in October and 124 times in November 2023. A review of Resident 3's medication administration record for December 2023 indicated the behavior of both asking repetitive questions and threatening others was documented with a single hashmark each time it was observed. The monitoring did not distinguish between observing repetitive questions or threatening others. From 12/1/23 through 12/13/23 there was a total of 55 hashmarks. A review of Resident 3's pharmacy Consultation Report dated 10/31/23, indicated the pharmacist reviewed the resident's medication and made a recommendation related to quetiapine.A GDR [gradual dose reduction- slowly lowering the dosage of a psychotropic medication] is not recommended at this time behaviors noted On 12/13/23 at 11 A.M., an observation was conducted in the common area. A coloring activity was arranged out on one of the tables. Resident 3 was observed approaching the activity table and was heard asking, Is this for me? Can I do this? A few minutes later after having not received an answer to her question, Resident 3 was heard asking again while standing at the activity table, Can I do this? Resident 3 appeared calm and appropriate. On 12/14/23 at 8:21 A.M., a joint interview and record review was conducted with the DON. The DON stated Resident 3 had poor recall and memory issues and would sometimes ask a question more than once because she forgot. The DON reviewed Resident 3's clinical record, including the resident's physician order for quetiapine and behavior monitoring AEB repetitively asking questions and threatening others. The DON stated he had worked in the facility for a year and had never seen Resident 3 threatening others. The DON stated behavior monitoring was reviewed with the psychiatrist to determine the appropriateness of the psychotropic medication, dosage, and if a GDR should be attempted. The DON stated Resident 3's behavior monitoring was unclear and that asking questions was very different from threatening others. The DON stated it was also unclear why asking repetitive questions would warrant receiving quetiapine as the resident had a poor memory. The DON stated the behavior that needed monitoring should have been repetitive questions related to fixating on something which was a psychotic feature and not a memory issue. The DON stated asking questions and threatening others were two distinct issues requiring separate monitoring and that it could not be determined which behavior the resident had when represented by one hashmark. The DON stated staff may have been documenting when the resident asked general questions or forgot and asked again which was not a behavior that required quetiapine. The DON stated this order for quetiapine and its monitoring needed clarification as there was a potential the resident may have been receiving an unnecessary psychotropic medication. On 12/14/23 at 2:20 P.M., a telephone interview was conducted with the facility's PC. The PC stated Resident 3's behavior monitoring for the use of quetiapine should have been clear. The PC stated administering quetiapine for asking repetitive questions due to memory issues would not be an appropriate use of a psychotropic medication. 3. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include schizophrenia, schizoaffective disorder, major depression, and delusional disorder. A review of Resident 5's physician's orders dated 9/16/19 indicated, Trazodone 50mg at bedtime for insomnia (sleep disorder). On 12/14/23 at 1:50 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 5's clinical record and stated there was no documentation the causes of the resident's insomnia had been investigated. The DON stated there was no documentation non-pharmacological interventions were attempted to help the resident sleep before administering a psychotropic medication. The DON stated this should have been attempted first. The DON stated Resident 5's Trazodone was being used off label (not for its intended use). The DON stated without investigating the causes of Resident 5's insomnia and attempting non-pharmacological interventions to address sleep, there was a potential for the resident to receive unnecessary medications. On 12/14/23 at 2:20 P.M., a telephone interview was conducted with the facility's PC. The PC stated the facility should investigate why a resident was having trouble sleeping and attempt non-pharmacological interventions to address the identified causes prior to administering a psychotropic medication for sleep. A review of Pragma Pharmaceuticals, LLC, (the manufacturer of Trazodone) Medication Guide dated 6/2017, indicated, .(Trazodone) DESYREL .indicated for the treatment of major depressive disorder (MDD) (1). DOSAGE AND ADMINISTRATION, Starting dose: 150 mg in divided doses daily. May be increased by 50 mg per day every three to four days. Maximum dose: 400 mg per day in divided doses (2.1) https://www.accessdata.fda.gov. The Medication Guide did not indicate Trazodone could be used for sleeping purposes or administered once a day at bedtime. A review of the facility's policy titled 3.8 Psychopharmacological Medication Use, revised 11/31/11 [sic], indicated, .1. Facility should comply with the .Center for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications

Based on observation, interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 2 score (indicates resident with intellectual disability) assessment was conducted in a timely manner for one of one resident (Resident 12) reviewed for Resident Assessment. As a result, Resident 12 did not have life enrichment opportunities available to her when indicated as a possibility following a positive PASARR Level 1 score (positive indicates a Level 2 assessment was required). Findings: Resident 12 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), per the facility's Admission Record. On 12/12/23 at 8:59 A.M., an observation and interview was conducted with Resident 12 within her room. Resident 12 was dressed, sitting on the side of the bed. Resident 12 was folding clean Kleenex tissues into smaller squares and had an open bible next to her. Resident 12 stated she enjoyed playing the piano, reading, sitting outside, and exercising. On 12/12/23, Resident 12's clinical record was reviewed. According to the facility's Admission PASARR, dated 12/22/21, a Level 1 was positive, indicating a Level 2 assessment was required to be conducted. There was no documented evidence located in the resident's clinical record, indicating a Level 2 assessment was completed, which would have offered outside education and activities for those residents who qualify. On 12/13/23 at 3:47 P.M., an interview and record review was conducted with the DON of Resident 12's clinical record. The DON stated if a PASARR Level 1's was positive, it meant a PASARR Level 2 assessment needed to be conducted. The DON stated nursing staff were responsible for completing part of the form and then an outside agency would come to the facility to complete the assessment and to make recommendations. The DON stated back in 2021, the ADM and ADM Assistant would usually monitor the PASARR assessments. The DON stated he could not locate any documented evidence a PASARR Level 2 had been conducted for Resident 12. The DON stated he would research and call the outside agency to see when Resident 12's PASARR Level 2 was completed. On 12/14/23 at 12:31 P.M., a follow up interview was conducted with the DON. The DON stated they called the outside agency and was referred to a web site, which showed Resident 12's PASARR Level 2 assessment was, in process, since 2021. The site indicated the outside agency was notified an assessment was required, but there was no indication the assessment was ever completed. The DON stated there was no documented evidence between the facility and the outside agency to inquire why the assessment had not been completed. The DON stated the outside authorities missed it and so did the facility. The DON stated with the delay of the Level 2 assessment, Resident 12 could have missed out on potential activities and classes which would have enriched her quality of life. On 12/14/23, the DON stated the facility did not have a policy related to PASARR assessments.

Based on observation, interview, and record review, the facility failed to ensure a Minimum Data Set Assessment (MDS, a comprehensive assessment) for one of eight residents (Resident 1) was accurate when Resident 1 was assessed as having a trach (opening into the trachea and breathing tube) and using a restraint (device that prevents freedom of movement). This failure had the potential to affect the care provided to Resident 1. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's MDS assessment dated [DATE], indicated under Section O for respiratory care, that the resident was marked as yes for having received tracheostomy (trach) care. The same MDS assessment under Section P for physical restraints, had the resident marked as having used a restrain in chair/out of bed. On 12/12/23 at 8:02 A.M., an observation of Resident 1 was conducted in the resident's room. Resident 1 was lying in bed with her eyes closed. Resident 1 was not observed to have a trach or a restraint. On 12/13/23 at 7:20 A.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated she had never seen Resident 1 with a trach or using a restraint of any kind. On 12/13/23 at 2:35 P.M., a joint interview and record review was conducted with the director of nursing (DON). The social services director was also present. The DON was responsible for ensuring the completion and accuracy of MDS assessments. The DON reviewed Resident 1's MDS assessment dated [DATE], and stated the resident did not have a trach and did not use restraints. The DON stated the MDS assessment had errors and was inaccurate. On 12/15/23 at 8:35 A.M., an interview was conducted with the DON. The DON stated the facility did not have a policy for conducting MDS assessments but that it was his expectation that MDS assessments be completed accurately and for the Resident Assessment Instrument (RAI) manual to be followed when completing MDS assessments.

Based on observation and interview, the facility failed to provide a homelike environment for two of three resident's (Resident 2 and Resident 16), reviewed for Environment. As a result, Resident 2 verbalized being afraid and Resident 16 verbalized being uncomfortable while in their beds. 1. Resident 2 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder, (a mental disorder that affects one's thoughts, mood and behavior), per the facility's Admission Record. On 12/12/23 at 2:16 P.M., an observation and interview was conducted with Resident 2 in her room. Resident 2 had the only single bedroom in the facility. Resident 2 was sitting up in bed, dressed, and reading a bible, with all her privacy curtains pulled around the bed. A mechanical lift (a large metal piece of equipment with a sling in the middle, used by medical staff to lift or move a non-ambulatory person from one place to another) was positioned with the base of the lift stored under the foot of her bed, and the two metal overhead sling arms hanging above the foot of the bed. Resident 2 stated she did not need or use the piece of equipment and she did not know why it was in her room, but it had been there for years. Resident stated, it scares me and she did not like having, that thing in her room. During initial tour of the facility, no residents were identified as needing a mechanical lift for assistance as all residents ambulated on their own. On 12/14/23 at 8:20 A.M., an observation and interview was conducted with the DON of Resident 2's room. Resident 2 was dressed and sitting up in bed with all the privacy curtains pulled around the bed. The DON observed the mechanical lift positioned at the foot of Resident 2's bed. Resident 2 stated, I have to look at it all the time and it's scary. The top metal sling arms were covered in dust. The DON stated the lift had been there as long as he had been at the facility (one year), and he was unaware it scared the resident. The DON stated the mechanical lift was not currently being used and it should be stored in the outside shed. The DON stated storing equipment in the resident's room did not promote a homelike environment and if it scared Resident 2, it should not be kept there. 2. Resident 16 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental disorder that affects one's thoughts, mood and behavior), per the facility's Admission Record On 12/12/23 at 9:03 A.M., an observation and interview was conducted with Resident 16 in his room. Resident 16 was dressed and lying on top of his bed. Resident 16 stated, I don't like my bed, I can feel the metal, can you help me get rid of the metal, it's very uncomfortable? Resident 16 lifted the bed sheet and there was no mattress pad. The mattress had several linear tears on the surface and circular metal springs could be seen protruding on the top of the mattress. Resident 16 stated he like to stay in bed, but the metal was uncomfortable, and he asked if he could have a different mattress. On 12/13/23 at 8:31 A.M., an interview was conducted with the DON. The DON stated they did not have a maintenance book. The DON stated if there was an issue, the staff would inform him or the administrator, who would call a company to come make the needed repairs. The DON stated they have a list of repair companies they use, because they do not employ a maintenance person. On 12/14/23 at 8:15 A.M., an observation and interview was conducted with the DON of Resident 16's room. Resident 16 was sitting on top of his bed and told the DON, the metal on my bed is very uncomfortable. Resident 16 lifted the bottom sheet and exposed the mattress. The DON ran his hand over the mattress and stated, I understand what you mean. The DON stated the mattress looked uncomfortable and was not homelike. On 12/14/23, the DON stated the faciity did not have a policy related to Homelike Environment.

Based on interview and record review, the facility failed to ensure informed consent was accurately obtained and documented for the medication doses, prior to administering psychotropic medications (medications which affect behavior, mood, thoughts, or perception and could have serious side effects) for two of five residents (Resident 2 and 13), reviewed for Resident Rights. As a result, Resident 2 and Resident 13, along with their conservators (when a judge appoints another person to act or make decisions on behalf of the resident), were not informed of the higher daily doses being received, which increased their risk of side effects and serious medication risk. Findings: 1. Resident 2 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder, (a mental disorder that affects one's thoughts, mood and behavior), per the facility's Admission Record. On 12/13/23, Resident 2's clinical record was reviewed for psychotropic use. Per the facility's Informed Consent for Psychotherapeutic Drugs, dated 6/24/22, the conservator consented and signed for the administration of Clozapine (used to treat severely ill patients with schizophrenia) 200 milligrams (mg) every night before bed. According to the physician's order, dated 7/8/23, Clozapine 100 mg tablet by mouth every morning .Clozapine two tablets (200 mg) by mouth before bed time . The Medication Administration Record (MAR) for July 1, 2023 through July 31, 2023 was reviewed. Resident 2 received Clozapine 100 mg every morning at 9 A.M. and received Clozapine 200 mg every evening at 9 P.M., for a total daily dose of 300 mg. There was no documented evidence an informed consent had been updated or prepared for the increased amount of Clozapine. On 12/13/23 at 9:20 A.M., an interview and record review was conducted with LN 1. LN 1 stated all medication nurses were responsible for verifying Informed Consent was obtained prior to the administration of a psychotropic medication. LN 1 stated Informed Consents were important to confirm a resident or their conservator was informed of why they were being prescribed the medication, the risk and benefits, and possible side effects. LN 1 reviewed the consent and physician orders for Resident 2's Clozapine, and stated the consent did not match the physician's order, since the medication dose was higher than listed on the consent. LN 1 stated the resident and conservator was not informed they were taking a higher dose, which increased the risk and side effects. On 12/13/23 at 9:27 A.M., an interview and record review was conducted with the DON. The DON stated informed consents were important to inform the responsible party's of the risk and it confirmed they agree with the current treatment plan. The DON reviewed Resident 2's Informed Consent, physician's order, and MAR. The DON stated the consent did not match the physician's order from July 2023, and the medication should not have been administered until the consent was updated with the correct daily dose of Clozapine. The DON stated he expected the LNs to confirm an accurate consent was on file, before the medication was administered. The DON stated Resident 2's conservator was not provided the correct information and was unaware the resident was receiving a higher dose. 2. Resident 13 was admitted to the facility on [DATE], with diagnoses which included psychosis (a severe mental disorder when one loses touch with reality) and tardive dyskinesia (a neurological disorder characterized by involuntary movements of the face and jaw caused by certain medications), per the facility's Admission Record. On 12/13/23, Resident 13's clinical record was reviewed for psychotropic use. Per the facility's Informed Consent for Psychotherapeutic Drugs, dated 6/24/22, the conservator consented and signed for the administration of Lorazepam (used to treat anxiety) 0.5 mg every night before bed. According to the physician's order, dated 6/27/22, Lorazepam 0.5 mg tablet, take 2 tablets (1 mg) by mouth every morning .Lorazepam 0.5 mg tablet, take 1 tablet by mouth at bedtime . The Medication Administration Record (MAR) for July 1, 2023 through July 31, 2023 was reviewed. Resident 13 received Lorazepam 1 mg by mouth every morning at 7 A.M. and received Lorazepam 0.5 mg every evening at 9 P.M., for a total daily dose of 1.5 mg. There was no documented evidence an informed consent had been updated or prepared for the increased amount of Lorazepam. On 12/13/23 at 10:43 A.M., an interview and record review was conducted with the DON of Resident 13's Informed Consent, physician's order, and July 2023 MAR. The DON stated the consent was not accurate, because Resident 13 was receiving a higher dose of Lorazepam, then first informed. The DON stated the higher dose, increased the risks and side effects. On 12/14/23 at 2:18 P.M., an interview was conducted with the Pharmacy Consultant (PC). The PC stated when he conducts his monthly medication reviews, he reviews the physician's order and the MAR. The PC stated he does not review the Informed Consents, because that was a nursing function. According to the facility's policy, titled Informed Consents, undated, .a .1. The right to receive all information in advance that is material to a decision to accept or refuse treatment .B. This shall be documented in the resident's health record .

Based on interview and record review, the facility failed to ensure one of five residents (Resident 7) reviewed for vaccines, had been offered the pneumococcal vaccine (used to prevent pneumonia infections). In addition, there was no documentation of the risks and/or benefits of the pneumococcal vaccine had been discussed with the resident or responsible party (RP). This failure had the potential for Resident 7 to not be adequately informed and protected from contracting pneumonia (a lung disease). Findings: A review of Resident 7's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of the undated facility infection prevention nurse (IPN) document titled (Facility Name) Immunization (a list of all 19 residents' vaccination status) indicated Resident 7 refused (no date listed) to receive the pneumococcal vaccine. On 12/13/23 at 2:51 P.M., a joint interview and record review was conducted with the facility's IPN. The IPN reviewed Resident 7's clinical record and stated there was no documentation of when the resident had been offered the pneumococcal vaccine or if the resident and RP had been informed of the potential risks and/or benefits of receiving the pneumococcal vaccine. The IPN stated Resident 7's refusal of the pneumococcal vaccine was not documented in the resident's clinical record. The IPN stated Resident 7 and the resident's RP should have been offered the pneumococcal vaccine more than once, educated on potential risks and benefits, and it should have been documented in the resident's clinical record. A review of the undated facility policy titled [Facility Name] Influenza and Pneumonia Vaccination Policy and Procedure, indicated, .It is also our policy to offer the vaccination for pneumonia to all residents

Based on interview and record review, the facility's pharmacy consultant (PC) failed to identify irregularities during the monthly drug regimen review (DRR) for one of eight residents (Resident 14), when Resident 14 received olanzapine (a psychotropic medication used to treat mental illness) without adequate indication for use and adequate monitoring. As a result, there was a potential for Resident 14 to receive unnecessary psychotropic medication. Findings: A review of Resident 14's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include traumatic brain injury and organic brain disease. A review of Resident 14's physician's orders dated 4/30/21, indicated olanzapine 2.5 mg (milligrams) take half a tablet PO (by mouth) every other day. Resident 14 Physician's Order dated 4/4/23, further indicated, Monitor episodes of agitation AEB [as evidenced by] refusing PO -[olanzapine] every shift. A review of Resident 14's Psychotropic Medication assessment dated [DATE] and 10/1/23, indicated there were zero episodes of refusing to take olanzapine observed in June, July, August, September, October, and November 2023. On 12/13/23 at 7:20 A.M., a joint interview and record review was conducted with licensed nurse (LN) 1. LN 1 reviewed Resident 14's physician orders dated 4/30/21 for olanzapine. LN 1 stated the physician's order should have clearly indicated what the medication was treating. LN 1 stated, I don't know why [Resident 14's] taking it. LN 1 reviewed Resident 14's clinical record and stated the resident did not have a psychiatric diagnosis (mental illness) but had a brain injury. LN 1 reviewed Resident 14's physician's order dated 4/4/23 for monitoring the resident's agitation AEB refusing olanzapine. LN 1 stated to take olanzapine for agitation when refusing to take olanzapine doesn't make sense. On 12/13/23 at 8 A.M., an interview was conducted with Resident 14. Resident 14 stated he only took one medication aside from vitamins and eye drops. Resident 14 stated he took olanzapine, half a pill, every other day. Resident 14 stated he did not know why he had to take olanzapine and that he would ask staff why and did not get an answer. Resident 14 stated years ago someone told him they thought he had schizophrenia (a mental illness). On 12/13/23 at 8:40 A.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 14's clinical record and stated he was not sure why the resident was taking olanzapine. The DON stated the physician's order did not have a clear indication for the use of olanzapine. The DON stated it should be clearly understood why Resident 14 was taking olanzapine, or there could be the potential the resident was receiving an unnecessary medication which could cause harm. The DON further stated there was no documentation of an appropriate diagnosis for the administration of olanzapine in the resident's active clinical chart. The DON stated Resident 14's behavior monitoring for agitation AEB refusing to take olanzapine doesn't make sense and circles around. The DON stated it was not acceptable to give olanzapine for refusing olanzapine and that the resident's order needed clarification. On 12/14/23 at 2:20 P.M., a telephone interview was conducted with the facility's pharmacy consultant (PC). The PC stated Resident 14's olanzapine monitoring was not appropriate and there should have been an adequate indication for the use of olanzapine in the physician's order. The PC stated Resident 14's order for olanzapine needed to be clarified. The PC stated he should have identified this as an irregularity during Resident 14's monthly DRR. A review of the facility's policy titled 9.2 Interim Medication Regimen Review revised 1/1/13, did not provide guidance related to identifying medication irregularities.