Royal Springs Healthcare and Rehab

Inspectors wroteBased on interview and document review, the facility failed to ensure annual dementia training was provided to 3 of 11 employees reviewed (Employee 1, 2 and 13). The deficient practice placed residents with dementia at risk for receiving inappropriate care.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to develop and implement a comprehensive care plan for the use of an electronic communication device (a camera) for audio and video recording for 1 of 40 sampled residents (Resident 7). The deficient practice placed residents, staff, and visitors at risk for violations of privacy, dignity, and confidentiality.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to revise the comprehensive care plan when modifications were made to a resident's nephrostomy tube for 1 of 40 sampled residents (Resident 29) and when a resident returned from the hospital under hospice care with a change in code status for 1 of 40 sampled residents (Resident 227). The deficient practice had the potential to negatively impact on the quality of care the residents received.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure documentation of care pertaining to a nephrostomy catheter site, suprapubic catheter site and Foley catheter site were factual and aligned with actual care provided for 1 of 40 sampled residents (Resident 29). The deficient practice placed residents at risk for receiving substandard quality of care.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure physician orders coincided with the documented treatment preferences as indicated on the Physician Order for Life Sustaining Treatment (POLST) form for 1 of 40 sampled residents, (Resident 32). The deficient practice had the potential for residents to receive medical interventions inconsistent with expressed wishes regarding life sustaining treatment.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure admission care orders which were transcribed into the medical record for a resident's nephrostomy tube, suprapubic catheter and Foley catheter were accurate, complete and were in accordance with facility policy and documented care for the resident's nephrostomy tube and suprapubic catheter aligned with actual care provided for 1 of 40 sampled residents (Resident 29). The deficient practice placed the resident at risk for recurrent urinary tract infection (UTI).

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure head of bed (HOB) was elevated during tube feeding infusion in accordance with the facility policy for 2 of 40 sampled residents (Resident 53 and 176). The deficient practice placed residents receiving tube feeding at risk for aspiration.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure psychotropic medication and opioid side effects were monitored for 2 of 40 sampled residents (Residents 7 and 64). The deficient practice had the potential to place residents at risk for experiencing adverse effects of medications.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) multiple medications were not crushed altogether instead of individually and 2) a medication with specific instructions to not crush was crushed and administered as such for one unsampled resident (Resident 217). The deficient practice resulted in a significant medication error and placed the resident at risk for potential adverse effects.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure:Open juice containers stored in the nourishment room refrigerator were labeled with an open date and a resident food item stored in the nourishment was labeled with the resident's name and used by date for 3 of 3 nourishment rooms refrigerators inspected. The deficient practice had the potential to increase the risk for foodborne illness.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure physician's order for life-sustaining treatment (POLST) was made available to emergency personnel for a hospice resident and failed to maintain hospice paperwork in the facility in accordance with the facility policy and hospice agreement for 1 of 40 sampled residents (Resident 227). The deficient practice resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advanced directives not being honored at end of life.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a sufficient number of nursing staff were scheduled to meet the needs of the residents during the weekends of December 2024 and January through February of 2025. The deficient practice placed the residents at risk for receiving inappropriate and delayed care.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to remove discontinued and expired medications and supplies from the active supply in 2 of 3 medication rooms. This deficient practice had the potential to result in medication errors, including the unintentional administration of discontinued medications, posing a risk to resident safety and well-being.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) level two referrals were completed for residents with newly identified psychiatric diagnoses for 5 of 35 sampled residents (Residents 24, 119, 110, 88 and 81). The deficient practice had the potential to deprive the residents of concern of necessary behavioral health services. Findings Include: Resident #24 (R24) R24 was re-admitted on [DATE], with diagnoses including congestive heart failure, type 2 diabetes mellitus, chronic pain syndrome, and bipolar disorder. A PASARR level one document dated 10/19/2018, revealed R24 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility (NF) placement. [...]

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure comprehensive care plans were revised to reflect new interventions, specifically, a nutrition care plan for 2 of 35 sampled residents (Residents 110 and 84) and a care plan for functional abilities and mobility for 2 of 35 sampled residents (Residents 156 and 67). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure restorative nursing services were provided for 2 of 35 sampled residents (Residents 156 and 67) . This failure had the potential to result in increased pain, worsening contractures, reduced mobility, and a decline in the resident's overall quality of life.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure feeding assistance was provided timely for residents with orders for one-on-one (1:1) feeding assistance with meals for 2 of 35 sampled residents (Residents 110 and 84). The deficient practice potentially contributed to the residents' significant weight loss.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the enteral feeding was completely delivered as ordered or the duration of the order was clarified for 1 of 35 sampled residents (Resident 105), and the head of the bed was elevated during enteral infusion for 1 of 35 sampled residents (Resident 136). This failure could result in inadequate nutrition and hydration and an increased risk of aspiration pneumonia or other complications for residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician's order for Oxygen (O2) use and care orders were obtained and implemented, and Oxygen saturation was monitored for 1 of 35 sampled residents (Resident 68). This deficient practice had the potential to result in improper Oxygen administration, delays in necessary treatment, and potential harm to the resident's health and well-being.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician's order for dialysis was transcribed, the dialysis access was monitored, and vital signs were obtained and documented pre- and post- dialysis for 1 of 35 sampled residents (Resident 166). This deficient practice could have the potential to increase the risk of bleeding, infection, hypotension, and inadequate dialysis, compromising the resident's health and safety.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment (FA) was updated to reflect accurate and current staffing needs of the facility and residents, and all required FA components were accurately documented. This deficient practice has the potential to deprive the residents of needed care.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance Performance Improvement Plan (QAPI) program 1) followed through on the facility's performance improvement project (PIP) for staffing shortage, 2) conducted a root cause analysis on the facility's high staff turnover rate, and 3) maintained oversight over low weekend staffing patterns. The deficient practice had the potential to negatively impact the quality of care provided to residents.

Inspectors wroteBased on observation, document review, and interview, the facility failed to prevent the following in a nourishment room: a staff member from consuming a drink, a trash can overflowed onto the floor, cubed ice placed inside a handwashing sink, and loose cubed iced on the bottom and around the food in a freezer. The failed practice had the potential to cause the spread of bacteria in the nourishment room.

Inspectors wroteBased on interview, record review and document review, the facility failed to assess, re-assess, and adequately monitor a resident with a change in condition for 1 of 4 sampled residents (Resident 3). The deficient practice: 1) resulted in an acute physical decline that contributed to the resident's emergent transport to the hospital where the resident passed away, and 2) placed facility residents who had a change in condition at risk for poor clinical outcomes.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident was treated with dignity and respect by facility staff not assisting with resident hygiene for 1 of 4 sampled residents. This had the potential to cause psychosocial distress to the resident.

Inspectors wroteBased on observation, interview, and document review, the facility failed to discard an expired food item and ensure 1 of 3 nourishment refrigerator temperatures were maintained. The deficient practice had the potential to place the residents at risk for a foodborne illness.

Inspectors wroteBased on observations, interview, and document review, the facility failed to ensure preventative maintenance (PM - the regular inspection, cleaning, and servicing of medical equipment to ensure they are in good condition and can perform their intended function correctly) was completed for medical equipment (Oxygen concentrators, nebulizer machines and enteral feeding pumps) utilized in the facility. The deficient practice had a potential for unmaintained, inefficient, and unsafe medical equipment used for resident care.

Inspectors wroteBased on interviews, record review, and document review the facility failed to ensure an advance directive acknowledgement was obtained for 2 of 35 residents (Residents 82, and 106)), and information was provided in a language the resident understands for 1 of 35 residents (Resident 276). The deficient practice had the potential to deny the resident of emergency medical treatment, the right to request, deny, or discontinue treatment.

Inspectors wroteBased on interview record and document review, the facility failed to ensure beneficiary discharge notifications were followed per Medicare delivery of notices guidelines and issuance of advance beneficiary notices for residents who decided to remain at the facility after skilled services were terminated for 3 unsampled residents (Resident 216, 217 and 215). The deficient practice had a potential for a resident/resident representative to not be properly informed of the termination of Medicare coverage and the potential financial costs of services if to remain at the facility.

Inspectors wroteBased on observation, interview, record and document review, the facility failed to ensure comprehensive care plans were revised for the management of edema (swelling) with the corresponding diagnosis for 1 of 35 sampled residents (resident 188). The deficient practice had a potential for staff not to provide personalized care for a resident.

Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure the following: 1) The consultation recommendation was followed for 1 of 35 sampled residents (Resident 188). 2) The coagulation laboratory test order was transcribed and completed prior to percutaneous endoscopic gastrostomy (PEG) (a flexible feeding tube inserted through the abdominal wall into the stomach, allowing direct delivery of nutrition, fluids, and medications) tube removal as ordered for 1 of 35 sampled residents (Resident 99), and 3) The medications were given within the prescribed time for 2 of 35 sampled residents (Residents 117 and 182). The deficient practices could have led to complications such as bleeding or clotting, ineffective treatment, a lack of necessary care, and compromised health and safety of the residents.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure hand rolls were applied as recommended for 1 of 35 sampled residents (Resident 70). The deficient practice had a potential for resident to develop further contractures of an extremity/joint.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure Neuro checks were completed and care plan updated following a resident's unwitnessed fall, for 1 of 35 Residents (Resident 138). The deficient practices had the potential to significantly increase the risk of injury from falls.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the suprapubic size 16 French urinary catheter was inserted or the order was clarified for 1 of 35 sampled residents (Resident 152). The deficient practice could have the potential to have caused trauma, severe discomfort, urinary complications, injury, or harm.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) The resident's percutaneous endoscopic gastrostomy (PEG) (a flexible feeding tube inserted through the abdominal wall into the stomach, allowing direct delivery of nutrition, fluids, and medications) tube was monitored post removal, cleansed, and the dressing changed, and 2) The pre- and post-PEG tube removal orders were transcribed as ordered, nothing by mouth status and clear liquid diet were implemented as ordered for 1 of 35 sampled residents (Resident 99). The deficient practices could have the potential to result in significant harm or complications, such as infection, improper care, missed necessary treatments, or other adverse outcomes.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure medication timed with meals was administered and documented as coded in the medication administration record (MAR) for 1 of 35 sampled residents (Resident 16). The deficient practice had a potential for a resident to miss out on a medication and to properly document missed doses of a medication.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a valid consent for the use of psychotropic medications was obtained for 1 of 35 sampled residents (Resident 57). The deficient practice had the potential for a resident/resident representative not being properly informed of the risk and benefits of a prescribed psychotropic medication.

Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 27 opportunities observed, calculating an error rate of 7.41 %. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure blood thinner or anticoagulant medication had been held before percutaneous endoscopic gastrostomy (PEG) (a flexible feeding tube inserted through the abdominal wall into the stomach, allowing direct delivery of nutrition, fluids, and medications) tube removal as ordered for 1 of 35 sampled residents (Resident 99). The deficient practice could have the potential to cause serious bleeding complications.