The Royal Home

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five resident rooms accommodated no more than four residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the minimum requirement of 80 square feet per resident for two of five resident rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards of practice when: 1. Staff failed to change gloves or do hand hygiene between residents when taking vital signs (VS- blood pressure, oxygen saturation, and temperature). 2. Staff failed to change gloves or do hand hygiene between resident interactions at mealtimes. 3. Proper handwashing was not consistently implemented in the kitchen. 4. The medication nurse did not do hand hygiene after changing gloves between administering medications to different residents. 5. Residents were not offered hand hygiene before meals. These failures had the potential to expose residents to infection or foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the physician's order for two residents (Resident 14 and 17) when: 1. The physician's instructions were not followed when pantoprazole sodium (a medication to treat acid reflux) was administered to Resident 14. 2. Resident 17 was administered acetaminophen without an active physician's order. These deficient practices had the potential for the facility to not be able to ensure pharmaceutical services were safely provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely stored when a resident's (Resident 14) vial of insulin (injectable hormone that controls a person's blood glucose levels) was stored in the medication cart and ready for resident use after being opened for longer than 28 days. This failure had the potential for Resident 14's insulin to no longer be effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt replacement of Resident 3's lost bottom partial denture. Resident 3's bottom partial denture has been missing for six months. This failure had the potential to effect the resident's ability to effectively chew food and increased the resident's risk for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure verification of informed consent for psychotropic medications (drugs that affect behavior, mood, thoughts, or perceptions) was complete and accurate for two residents (Resident 12 and 14). As a result, it could not be determined that informed consent had been verified according to the facility's policy.

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify, develop, and implement an action plan related to acceptable standards of practice for hand hygiene and glove use among staff and residents (Cross reference F880). This failure had the potential to affect the health and safety of the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence that 3 of 6 residents (Resident 12, 18, and 19) were screened, offered, and that a clinical discussion between the residents/responsible party (RP) and the physician, regarding the pneumonia vaccines, was conducted in accordance with acceptable infection control standards. This failure had the potential for residents to contract pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five resident rooms accommodated no more than four residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the minimum requirement of 80 square feet per resident for two of five resident rooms.