Health inspection·April 10, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of the Face Sheet, for Resident 9, the Face Sheet, indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses which included depression (feeling sadness) and alzheimer's disease (memory loss). The physician's order, dated 07/29/24, indicated Resident 9 should receive Aripiprazole (Abilify) 2 milligrams (mg) by mouth at bedtime for the treatment of depression. This medication was classified as an antipsychotic and requires monitoring to assess both its effectiveness in managing the targeted condition and the presence of any side effects or adverse reactions. Upon review of the behavior monitoring and side effect tracking tool for Resident 9, the documentation showed that only side effect monitoring was being conducted, such as assessments for drowsiness, dizziness, or extrapyramidal symptoms. There was no documentation of behavioral monitoring, including identification of target behaviors, baseline symptoms, or ongoing evaluations of whether the medication was effective in addressing the resident's depression. In an interview on 04/09/25 at 10 a.m., the Quality Assurance Nurse confirmed that behavioral monitoring had been overlooked and stated, It should have been filled out, but was missed. Based on observation, interview, and record review, the facility failed to ensure two of 17 sampled residents (Resident 9 and Resident 19) were free of unnecessary psychotropic medications (drugs that affect brain function, mood, thoughts, or behaviors) when: 1. Staff did not implement non-pharmacological interventions (treatments that do not involve medication prior to administering psychotropic medications) for Resident 19. 2. Staff failed to implement behavioral monitoring related to the use of psychotropic medications for Resident 9. These failures had the potential to result in unecessary drug administration for Residents 9 and 19. Findings: 1. During a review of the Face Sheet for Resident 19, the Face Sheet indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During an interview on 4/9/25 at 8:28 a.m., with Resident 19, Resident 19 stated he notified staff that he was not sleeping well because he experienced jerking episodes throughout the night which had been keeping him awake. Resident 19 stated the physician ordered a sleeping pill. During a review of Resident 19's record on 4/9/25 at 8:35 a.m., the record indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm On 2/2/24, the physician ordered Melatonin (a supplement used to regulate sleep cycle) at bedtime as needed. On 3/24/25, the physician ordered Temazepam (psychotropic medication-sleeping pill) for insomnia (trouble sleeping) at bedtime as needed. There was no documentation of any non-pharmacological interventions. Residents Affected - Few On 3/24/25, a Nursing Care Plan was developed for Insomnia. Interventions included, Administer Temazepam. There were no non-pharmacological interventions planned to address the resident's insomnia. On 4/1/25, the physician ordered Trazodone (psychotropic medication-sleeping pill) for insomnia at bedtime as needed. There was no documentation of any non-pharmacological interventions. During a concurrent interview and record review on 4/9/25 at 3:16 p.m.,with License Vocational Nurse (LVN) 2, Resident 19's April 2024, Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 19 received Trazodone on 4/1/25, 4/4/25, 4/5/25, 4/6/25, and 4/7/25. There was no documentation which indicated non-pharmacological interventions were attempted prior to administering Trazodone on each date. The MAR further indicated Resident 19 did not receive Melatonin between the dates of 4/1/25 through 4/9/25. LVN 2 stated she did not offer Resident 19 Melatonin prior to administering Trazodone. LVN 2 confirmed there was no documentation in the record which indicated non-pharmacological interventions were attempted prior to administering Trazodone. During a concurrent interview and record review on 4/10/25 at 8:20 a.m., with Director of Nursing (DON), DON stated prior to starting a psychotropic medication, non-pharmacological interventions should have been attempted and documented in the resident's record. Resident 19's March and April 2025 MAR were reviewed with the DON, the DON confirmed there were no non-pharmacological interventions documented prior to administering the psychotropic medications to Resident 19. DON confirmed there was no documentation to show Resident 19 was offered Melatonin to help him sleep in March or April 2025. DON stated Melatonin and non-pharmacological interventions should have been attempted prior to administering psychotropic medication. During a review of the facilities policy and procedure (P&P) titled, Psychotropic Drug Management, SNF, last reviewed 10/21/24, P&P indicated, Resident's care plan will include behavioral interventions implemented in an attempt to decrease the target behaviors . Non-pharmacological, or behavior interventions were attempted, but failed to resolve the cause of the behaviors . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-eight opportunities, resulting in an error rate of 10%, and involved two separate insulin administrations and one nasal spray medication for Resident 3. These deviations from proper technique posed a risk for suboptimal therapeutic outcomes. The failure to adhere to manufacturers' instructions for insulin and nasal spray administration not only violates professional standards of practice but also increases the risk of therapeutic failure and resident harm. Residents Affected - Few Findings: 1. According to the manufacture's insert instructions for insulin (#1), the dose button must be held in and the needle kept in the skin for at least five seconds to ensure full dose delivery. Similarly, manufacture's insert instructions for insulin (#2) once the dose button was pressed, the needle should remain under the skin for six seconds. Failing to follow these steps may result in an incomplete dose being delivered. During a review of the Face Sheet for Resident 3, the Face Sheet, indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) and muscle weakness. On 4/7/25 at 8 a.m., during medication administration observations, Licensed Vocational Nurse (LVN) 1 was seen administering insulin #1 and insulin #2 to Resident 3. In both instances, the nurse inserted the insulin pen needle and immediately withdrew it after pressing the dose button, without holding the needle in the subcutaneous tissue for the duration specified in each manufacturer's instructions for use. During an interview on 4/7/25 at 8 a.m., at the time of observation, the LVN 1 acknowledged the error and stated, I forgot about holding that insulin needle in the patient as required by the manufacturer. She confirmed that she routinely removed the pen immediately after pressing the dose button and was not consistently following the manufacturer's holding time guidance. 2. According to standard manufacturer's instructions for most Saline Nasal Spray-intranasal sprays, the nasal passages should be cleared (individual should blow their nose) prior to administration to ensure the medication contacts the mucosa effectively. On 4/7/25 at 8 a.m., during medication administration observations, LVN 1 administered a nasal spray to a Resident 3 without instructing the resident to blow their nose beforehand. When interviewed, the LVN 1 stated, I just didn't know that you were supposed to blow the nose for the nasal spray. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, leadership interview and dietary department document review the facility failed to ensure sufficient staff were employed as evidenced by the lack of a full-time qualified position to supervise and manage the day-to-day operations of the skilled nursing dietetic services. Failure to ensure sufficiently qualified staff may result in dietetic services that are inconsistent with professional standards of practice placing 35 residents at risk for potential food related medical complications. Findings: Per California Code of Regulations, Title 22, Chapter 3, dietetic services is defined as the provision of safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies. Additionally, California Health and Safety Code, 1265.4 describes the staff qualifications for the day-to-day management of dietetic services in a skilled nursing facility. The Health and Safety Code describes, in the absence of a full-time Registered Dietitian with supervisory responsibilities for dietetic services, the licensed facility shall employ a full-time qualified dietary services supervisor. There are 7 recognized pathways, all of which are based on a variety of educational experiences. During the initial tour of the main kitchen on 4/7/25, beginning at 8:20 a.m. the surveyor was introduced to the Food Manager (FM). In a concurrent interview, the FM indicated he was responsible for the day-to-day management of both the skilled nursing kitchen, as well as a separately licensed residential care facility for the elderly (RCFE). The FM indicated primary food production activities occurred in the RCFE kitchen with some menu items also produced in the skilled nursing facility (SNF) kitchen. The FM acknowledged his position was not dedicated as full-time to the SNF, rather had foodservice responsibilities for multiple levels of care. The surveyor was also introduced to the Dietetics Assistant Director (DAD), a Registered Dietitian. The DAD indicated her position was responsible for supervisory oversight of the Registered Dietitians as well as the Food Service Managers for both the RCFE, as well as the SNF. The DAD position also included the responsibility of all departmental administrative functions such as staffing and budget. In an interview and concurrent document review on 04/08/25 at 1:30 p.m., with the DAD the organizational chart for the veterans home was reviewed. The DAD indicated the Director of Dietetics position, as well as a food service supervisor (FSS) II position was currently vacant. The DAD indicated that within the current organizational structure there is no position designated to be the full-time qualified Food Service Director dedicated to the skilled nursing facility. The DAD confirmed all of the dietetic services leadership positions within the home are split between the RCFE and the SNF. The DAD acknowledged her position was not dedicated solely to the SNF. The surveyor also reviewed the responsibilities of the Registered Dietitian (RD) within the SNF. The DAD indicated one of the RD positions was dedicated to the SNF, however the position did not include day to day management of dietetic services for the SNF, rather the focus was clinical nutrition care. In an interview on 04/09/25 at 10:15 a.m., the Assistant Administrator (AA) 1 for the home indicated the process for vacancies was to post a position, which was done by Human Resources (HR) in Sacramento. The applications were then forwarded to the departmental supervisor for screening and selection of candidates to interview. The screening then goes back to Sacramento HR for final review who will determine the final candidates eligible for interview. Concurrent review of the Minimum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few qualifications for the FSS II revealed one of the qualification pathways would be consistent with the regulatory requirements, however there were others that were based solely on experience. The AA 1 indicated he can move positions within an organizational structure at the local level, however position duties would be more difficult to modify and would need to be taken through HR channels. The AA 1 indicated to his knowledge the home had not attempted to make modifications to position descriptions and/or position minimum qualifications. The AA 1 indicated a RD used to be responsible for the day-to-day supervision of the SNF kitchen, however she returned to a clinical nutrition role. Additionally, the AA 1 indicated the home had approved the FM to receive the necessary training as outlined in the California Health and Safety Code. In an interview 04/09/25 at 11:40 a.m., the Registered Dietitian (RD) 1, RD 1 stated she alternates working in the SNF and in the RCFE. The RD 1 stated she does a monthly kitchen inspection at the SNF, completes weekly test trays and helps in the kitchen if they are short staffed. RD 1 indicated she did a monthly sanitation inspection which includes elements such as an evaluation of labeling/dating, food temperatures, observation of staff for hand hygiene and clean up after trayline and temperature testing for food storage. RD 1 acknowledged she does not have supervisory responsibilities for the day-to-day operation of the SNF dietetic services. In an interview on 04/09/25 at 1:10 p.m., the FM stated while he started the coursework to become Certified Dietary Manager, but he has not completed it. Review of the position description for the DAD indicated this position was responsible for assisting in the management of the home's Registered Dietitians and Food and Nutrition operations. The position description for the Food Manager indicated under the direction of Director of Dietetics the position plans, directs and coordinates food service activities. The position description of the Registered Dietitian indicated under the direction of the Director of Dietetics this position completes nutrition assessments and provides medical nutrition therapy. Review of undated, facility policy titled Food & Nutrition Services-Staff Operations and Training (All Homes) documented .Staffing Standards .A. Skilled Nursing (SNF) .2. If a dietitian is not employed full-time, a full-time Food & Nutrition Services supervisor will be employed to be responsible for the operation of the food service . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, dietary and leadership staff interview and departmental document review the facility failed to ensure food handling practices were consistently carried out in accordance with food safety standards when: 1. There were lapses in cooldown monitoring of foods associated with foodborne illness and 2. One staff member was chewing gum during food production activities. These failures had the potential to result in foodborne illness and cross-contamination for the facility's residents. Findings: 1. Potentially Hazardous Foods (PHFs) are those foods capable of supporting bacterial growth associated with foodborne illness. Protein based foods such as meat, beans and canned tuna are considered PHFs and require time/temperature control for food safety during periods of preparation, storage and distribution (US Department of Agriculture [USDA], Food Code, 2022). Cooked foods requiring time/temperature control for safety food shall be cooled: within 2 hours from 135ºF (degrees Fahrenheit) to 70°F and within a total of 6 hours from 135ºF to 41°F or less. Food shall be cooled within 4 hours to 41°F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna (USDA Food Code, 2022). During initial tour observation of the main production kitchen on 04/07/25 beginning at 08:20 a.m., there were multiple pans of frozen entrée foods in Freezer #B. The following foods included, but not limited to, Macaroni and Cheese, dated 2/13/2025 and cooked corned beef, dated 3/15/2025. It was also noted in Refrigerator #A there was approximately one-half gallon of prepared tuna salad, dated 4/6/25. In a concurrent interview the Food Manager (FM) indicated that some of the frozen items were over production and would be used at a later time as a meal substitute. The FM also stated there were various food production methods for the skilled nursing facility (SNF) kitchen. He stated depending on the item and dietary department staffing food items may be prepared in the main kitchen and then transported to the SNF kitchen for distribution, while others may be prepared in the SNF kitchen. During a food production observation on 04/08/25 at 09:20 a.m., the surveyor asked [NAME] (C) 1 to describe the process for preparing tuna salad. C1 indicted the tuna and mayonnaise were stored at room temperatures in the dry storage area. C1, indicated if there was mayonnaise in the refrigerator it would be used first. C1 described the process of mixing the ingredients then placing the finished product in the refrigerator. C1 indicated there was no temperature monitoring during the food storage period, rather temperatures were taken shortly prior to using the tuna. In a concurrent confirming interview with the FM he acknowledged the facility did not monitor food temperatures for items prepared from ingredients at ambient (room) temperature. The surveyor asked C1 to describe the process when there was an overproduction of an item that was intended to be saved for later use. C1 indicated the item would be taken from the hot line and moved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to either the refrigerator or freezer and if it did not cool down fast enough, they would utilize the blast chiller (an appliance to quickly cool foods to a low temperature). C1 and the surveyor proceeded to Freezer #B where dietary staff were storing previously cooked items. The following cooked items were present: macaroni and cheese, dated 2/13/25; vegetarian meatloaf, dated 3/16/25 and lentil loaf, dated 3/15/25. Concurrent review of the departmental document titled, Cool Down Log, dated 2/10/25 through 4/7/25 revealed none of the observed items in the freezer were monitored during the cooldown process. In a concurrent interview FM acknowledged there was currently no system to monitor cooldown temperatures for foods prepared from room temperature ingredients. The undated, facility policy titled, Food & Nutrition Services-Leftover and Extra Food (All Homes) guided staff on the process of properly cooling foods, however, did not include guidance for documenting the process. It was also noted the policy did not address the necessity to monitor the cooldown of PHFs from room temperature ingredients. 2. During general food production observations on 4/7/25 beginning at 10:55 a.m., it was noted Food Service Worker (FSW) was preparing mechanically altered items for the noon meal. FSW was consistently moving her mouth in a chewing motion, resembling the motion of chewing gum. During an general conversation with FSW the surveyor noted a white item in her mouth resembling gum. The surveyor asked if she had gum in her mouth to which she stated, I Do. The undated, departmental policy titled, Food & Nutrition-Staff Operations and Training (All Homes) indicated, .Eating/Drinking/Tobacco/Gum in Work Areas . 3. Employees must not chew gum .in kitchen or serving areas . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a complete and accurate medical record when consent for the use of psychotropic medication (drugs that affect brain function, mood, thoughts, or behaviors) was not documented in the medical record for one of 12 sampled residents (Resident 19). This failure had the potential for Resident 19 to receive psychotropic medication that the resident did not consent to leading to unwarranted side effects. Findings: During a review of the Face Sheet, for Resident 19, the Face Sheet, indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During a concurrent interview and review of Resident 19's record on 4/8/25 at 2:53 p.m., with the Director of Nursing (DON), the following physician's orders were reviewed: On 3/24/25, the physician ordered Temazepam (psychotropic medication used to aid sleep). On 4/1/25, the physician ordered Trazodone (psychotropic medication used to aid sleep). There was no documentation which indicated Resident 19 consented to receive the psychotropic medications. DON stated the ordering physician was responsible discussing the treatment with Resident 19 and for obtaining signed written consent from the resident. DON stated it was important to have written consent in the resident's chart so the medication nurse could verify that Resident 19 consented to receive the psychotropic medication prior to administration of the medication. During an interview on 4/8/25 at 3:37 p.m., with Registered Nurse (RN), RN stated the physician should obtain the Resident's signature on the consent for psychotropic medication form and nursing staff should verify the consent form was signed prior to administering psychotropic medication. RN stated psychotropic medication should not be administered without the resident's consent documented in the record. During a review of Resident 19's Medication Administration Record (MAR), the MAR indicated Resident 19 received Temazepam on 3/24/25, 3/26/25 through 3/31/25, and Trazodone on 4/1/25, 4/4/25 through 4/7/25. During a review of the facility's policy and procedure (P&P) titled, Informed Consent (All Homes), dated 2/28/25, indicated, Written information must include in the written psychotherapeutic drug informed consent . Informed consent will be filed in the Residents' health record . Psychotropic medication therapy informed consent forms will be used by the prescriber to document informed consent for new psychotropic medication orders . The licensed nurse will verify that the Resident's health record contains the documentation that the Resident or resident representative has given informed consent to the proposed treatment or psychotropic drug prior to initiating treatment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555891 If continuation sheet Page 9 of 9