Royal Terrace Healthcare

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 6) rights were not violated when the facility did not allow Resident 6's family member to visit the resident. This deficient practice had the potential to worsen Resident 6's depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and cause emotional and psychosocial impairments. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 1/27/2026 with diagnoses which included depression, malignant neoplasm of endometrium (cancer that starts in the endometrium, the inner lining of the uterus [womb]), and hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being on 6/8/2026 evening shift (from 3 PM to 11 PM). This deficiency practice resulted in incomplete activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) documentation on 6/8/2026 evening shift for one of three sampled residents (Resident 7) and having the potential for all residents not receiving services to meet their needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 23 and 36) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 23's diagnosis of depression (feeling of deep sadness that made a resident lose interest in things they once enjoyed) was coded in MDS assessment dated [DATE]. b. Ensure Resident 36's use of antipsychotic medication was coded accurately in the MDS assessment dated [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for two of two sampled residents (Residents 2 and 36) by failing to: a. Develop an individualized CP to address the diagnosis of depression (feeling of deep sadness that made a resident lose interest in things they once enjoyed) for Resident 2. b. Develop an individualized CP to address the diagnosis of dementia (a progressive state of decline in mental abilities) for Resident 36. These failures resulted in the residents not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care for three of three sampled residents (Residents 2, 7, and 36) when:a. The facility did not document the blood sugar level on Resident 2's medical record. b. The facility did not rotate the insulin (a hormone that helped a resident's body use sugar for energy) administration site for Resident 2.c. The facility did not document the psychotropic medication monitoring every shift when Resident 36 was taking citalopram hydrobromide (medication for depression [feeling of deep sadness that made a resident lose interest in things they once enjoyed]) and quetiapine fumarate (medication for psychosis [when a resident lost touch with reality]). d. The facility did not rotate the insulin administration site for Resident 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen, by failing to: a. Discard five cups of vanilla ice cream dated 5/18/2026 that had spilled over in the kitchen Refrigerator 1. b. Discard one pitcher of prune juice with a use by date of 5/14/2026 in the kitchen Refrigerator 1. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling and storage of food brought into the facility in one of one resident's refrigerator, by failing to: a. Discard one container of peanut butter and chocolate chip frozen dessert and one container of strawberry ice cream with no name or expiration date. b. Discard one cup of vanilla ice cream with no name or expiration date that was sealed with a plastic wrap. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices in accordance with its policy and procedure, when: a. Two of two unlabeled wash basins were stacked on top of each other and placed on the floor underneath the sink located in the shared bathroom between Rooms A and B. b. The resident's urinal (container used for urination) was placed on the nightstand for one of one sampled resident (Resident 58). These deficient practices had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect for one of one sampled resident (Resident 4) when Licensed Vocational Nurse 3 (LVN 3) failed to feed Resident 4 at eye-level on 5/19/2026 during Resident 4's lunch meal. This deficient practice resulted in the violation of Resident 4's right to a dignified existence and had the potential to affect Resident 4's feelings of self-worth and self-respect

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 60) who was admitted in the facility with pressure induced deep tissue damage (damaged skin caused by staying in one position for too long) received care and services to promote wound healing by failing to accurately monitor and assess the correct settings of the low air loss mattress (LALM - tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float, designed to prevent and treat pressure sores, or pressure ulcers) according to Resident 60's weight. This deficient practice placed Resident 60 at risk of poor wound healing and deterioration of current pressure induced deep tissue damage.

Inspectors wroteBased on observation, interview and record review, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis (working 40 or more hours a week) from 12/9/2025 to 12/23/2025 for 52 of 52 residents (census) in the facility. This deficient practice had the potential to impact the quality of care and outcomes that all residents experience in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards possible and residents received adequate supervision for two of three sampled residents (Residents 2 and 3) when:a. Resident 2's bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) did not sound when Resident 2 got up from Resident 2's bed unassisted by staff and walked to the bathroom.b. The facility's licensed nursing staff (in general) failed to conduct a fall risk assessment (an evaluation to determine a resident's likelihood of falling) or inaccurately assessed Resident 3 as low risk for fall following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents right to be free from sexual abuse for one of three sample residents (Resident 2). This deficient practice resulted in Resident 2 being subjected to indecent exposure when Resident 1 masturbated in the room in front of Resident 2, and Resident 2 was afraid to go to sleep because Resident 2 feared for his safety. [...]

Inspectors wroteCross Reference F600Based on interview and record review, the facility failed to ensure residents the right to be free from sexual abuse for one of three sample residents (Resident 2). Based on interview and record review, the facility failed to provide supervision of Resident 1, when he inappropriately exposed himself and masturbated in the presence of Resident 2, after the facility had knowledge of another incident that had occurred where Resident 1 exposed himself masturbating to other residents in the hallway. This deficient practice had the potential to result in Resident 1's behavior to cause psychosocial harm to Resident 2 and other residents if the facility staff did not monitor Resident 1's whereabouts. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate a care plan for one of three sampled residents (Resident 1) which addressed Resident 1's behavior of inappropriately exposing himself and masturbating in the presence of Resident 2 and other residents in the hallway. 1. This deficient practice had the potential to result in psychosocial harm to Resident 2 and other residents in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received interventions for the risk of elopement (a resident leaves the premises or a safe area without the facility's knowledge) when Resident 1 expressed to RN 1 that Resident 1 wanted to leave the facility. This failure resulted in Resident 1 leaving the facility unsupervised on 9/7/2025 and had the potential for Resident 1 to be injured.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary (needed) care and services to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Changes in Resident Condition, when:a. Registered Nurse (RN) 3 and LVN 1 did not notify Resident 1's physician regarding Resident 1's complaint of pain and not feeling well, and Resident 1's request to be transferred to a General Acute Care Hospital (GACH) on 7/20/2025 during the 3-11 shift (3 PM to 11:30 PM).b. Registered Nurse (RN) 3 and LVN 1 did not document Resident 1's complaint of pain and not feeling well, and Resident 1's request to be transferred to a GACH in Resident 1's medical record on 7/20/2025.c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) and AD Acknowledgement Forms were filled out completely and correctly and added to the resident's medical record for two of three sampled residents (Residents 3 and 93) in accordance to the facility's policy and procedure (P&P) titled Advance Directives. This deficient practice had the potential to cause confusion among the healthcare workers in the event Residents 3 and 93 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage in one of one facility's kitchen by failing to: a. Ensure leftover food from outside the facility was not stored in the kitchen refrigerator. b. Label food items and supplies in the dry storage area with a date open receipt, opened and used/best by date. c. Discard expired food items in the dry storage area. These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that would lead to foodborne illness (an illness caused by eating contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for one of one sampled resident (Resident 30) when staff did not close the privacy curtain while checking Resident 30's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. This deficient practice violated Resident 30's right to bodily privacy and resulted in unnecessary exposure of Resident 30's abdominal area and lower extremities. This deficient practice had the potential to affect Resident 30's psychosocial (mental and emotional) well-being, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when needed) was within reach and appropriate to the patient's physical ability for one of one sampled resident (Resident 29). This failure had the potential to result in a delay in meeting Resident 29's needs for assistance and could have led to a fall or accident.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized and comprehensive hospice plan of care for one of two sampled residents (Resident 95). This failure had the potential for Resident 95 to not receive the necessary care, treatment, and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Low Air Loss (LAL) mattress (Alternating Pressure Mattress which provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure injury which is a localized damage to the skin and underlying soft tissue usually over a bony prominence and maybe caused by intense or prolonged pressure over the site) was set up accurately according to manufacturer's instruction for one of two sampled residents (Resident 6). This deficient practice had the potential to result in the risk of reoccurring of pressure injury for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents had a dialysis emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for one of three sampled residents (Resident 93). This failure had the potential to result in Resident 93 to not receive or to receive delayed care and emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer Dilaudid (a controlled pain medication) within ordered parameters for one of four sampled residents (Resident 193). This failure resulted in professional standards of practice not being followed and had the potential to ineffectively manage Resident 193's pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication refrigerator (MR) was maintained at a temperature between 36 degrees Fahrenheit (F, unit of measurement for temperature) to 46 degrees F for one of one sampled medication refrigerator. This failure had the potential to result in medications stored in the medication refrigerator to become unstable and ineffective.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for two out of twenty-three resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of three sampled residents (Resident 9 and 99): a. To perform a screening for Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual became incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) upon admission and to obtain a copy of AD to keep/maintain in Resident 99's medical record (MR). b. To ensure Resident 9's AD acknowledgement form was filled out completely. These failures had the potential for the facility staff to provide treatment against the resident's will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) line and peripheral intravenous (PIV, a short , flexible plastic tube that is inserted into a vein through the skin) line for three of three sampled residents (Residents 43, 46 and 200) by failing to : a. Ensure the PICC line port was covered with a cap and not left open and exposed to the air, when not in use in accordance with the facility's Policy and Procedure (P&P) on Guidelines for Preventing Intravenous Catheter-Related Infections. b. Label and date the PIV for Resident 200) in accordance with the facility's P&P titled Peripheral IV Dressing Changes. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receiving oxygen therapy (a treatment that provides with extra oxygen to breathe in) were provided necessary respiratory care and services for four of four sampled residents (Residents 25, 27, 151 and 199) in accordance with the facility's Policy and Procedure (P&P) on Respiratory Therapy - Prevention of Infection. These failures had the potential to result in respiratory complications and infection for Residents 25, 27, 151 and 199.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 19) who had a diagnoses of Cystitis (inflammation of the bladder) and on Bactrim ([sulfamethoxazole/trimethoprim] medication that treat infection) as indicated in the facility's policy and procedure, titled Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 19 to not receive necessary care, treatment and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a smoking assessment (an assessment that helps to determine how can help a patient who smokes) upon admission for one of two sampled residents (Resident 100). This failure had the potential to result in unsafe smoking behaviors causing harm to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to a resident who used a plate guard (a dining aid that can help people with limited hand control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of two sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1's decline in nutritional status and inability to maintain independence during mealtime.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was accurately documented for one of three sampled residents (Resident 25). This failure had the potential to result in miscommunication among health care providers, resulting in inconsistent care for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 23 rooms (rooms [ROOM NUMBERS]) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteBased on interviews and record review, the facility failed to accommodate the needs and preferences of one of four sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's call light (device used by a resident to signal his need for assistance from the facility staff) was answered in a timely manner. 2. Ensure Certified Nursing Assistants (CNAs) assisted Resident 1 with Activities of Daily Living (ADL) in accordance with the resident assessment and care plan, including to assist when getting out of bed (OOB). 3. Ensure Resident 1 was not left soiled in urine for prolonged periods of time. These failures had the potential to result in a decline in Resident 1's physical and psychosocial well-being due to possible skin breakdown, loss of dignity, and loss of a homelike environment. (Cross Reference with F725)

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an individualized care plan for six of 15 sampled residents (Residents 7, 9, 10, 11, 13, & 14) in accordance with the physician's orders by failing to: A. Ensure there was a physician's order for the intervention Assisted Active Range of Motion (AAROM, joint receives partial assistance from an outside force) exercises to both lower extremities (BLEs) in Resident 7's care plan. B. Perform Passive ROM (PROM, outside force exclusively causes joint movement) exercises to Resident 9's right upper extremity (RUE) as indicated in the care plan. C. Perform PROM exercises to Resident 10's BLEs and RUE as indicated in the care plan. D. Perform PROM exercises to Resident 11's BLEs as indicated in the care plan. E. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide restorative nursing services (RNS, services provided to help residents maintain their function and joint mobility) as ordered by the physician for six of 15 sampled residents (Residents 7, 9, 10, 11, 13, & 14). A. For Resident 7, Restorative Nursing Aide (RNA) services were not provided for 5 days in 4/2024. B. For Resident 9, RNA services were not provided for 4 days in 4/2024. C. For Resident 10, RNA services were not provided for 6 days in 4/2024. D. For Resident 11, RNA services were not provided for 3 days in 4/2024. E. For Resident 13, RNA services were not provided for 3 days in 4/2024. F. For Resident 14, RNA services were not provided for 4 days in 4/2024. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure sufficient nursing staff, including certified nursing assistants (CNAs, staff to provide care to residents and assist with mobility ) and restorative nursing aides (RNAs, staff to help improve and/or maintain residents' function and joint mobility), were assigned to provide care for seven of 15 sampled residents (Residents 1, 7, 9, 10, 11, 13, & 14) in accordance with the residents' needs and preferences, physician's orders, and/or residents' care plans by failing to: A. Accommodate Resident 1's needs and preferences regarding the call light response time, getting out of bed (OOB), and incontinence brief changes. B. Provide Restorative Nursing Aide (RNA) services to Resident 7 as ordered by the physician in 4/2024. C. Provide RNA services to Resident 9 as ordered by the physician in 4/2024. D. [...]

Inspectors wroteBased on interviews and record review, the facility failed to verify the competencies and skills sets of the nursing staff to ensure appropriate nursing care and services were provided to the residents by failing to: A. Ensure three of nine sampled Certified Nursing Assistants (CNAs) had an active CNA certification. B. Ensure Director of Staff Development 1 (DSD 1) conducted a Skills Competency test for two of three sampled newly hired CNAs prior to working independently as a CNA. C. [...]