Royal Wood Mill Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide services that meet professional standards of quality as evidenced by failing to implement physician's orders for one Resident (#30), out of a total sample of 23 residents. Specifically, for Resident #30, the facility failed to implement a physician's order to administer Pyridostigmine Bromide (a medication to treat orthostatic hypotension/low blood pressure).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, with known behaviors of being intrusive and rummaging, the Facility failed to ensure they provided an environment free from accident hazards, when Resident #1 was able to get a hold of and consumed an object not meant for human consumption.

Inspectors wrote2. Review of the facility policy titled Administering Medications, dated August 2024, failed to indicate that the nurse is to check the medications against the physician's orders. During medication pass on 4/7/25, at 8:48 A.M., Nurse #3 told the surveyor that her medication cart computer was broken. Nurse #3 then said that she was stationing her medication cart near the nurse's station because she was using the computer at the nurse's station to pass medications. The surveyor then observed Nurse #3 read from the computer at the nurse's station. Nurse #3 then returned to the medication cart where she dispensed four medications into a medication cup from memory. The surveyor then observed Unit Manager (UM) #1 print out a list of 3 more medications and hand the list to Nurse #3. Nurse #3 dispensed the medications from the list. [...]

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically: 1. The facility failed to ensure medication and treatment carts were locked while a nurse was not present and failed to ensure medications were not left unattended on top of the medication cart when a nurse was not present. 2. The facility failed to ensure medications were not left at the bedside for one Resident (#64) out of a total of 20 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medical records were complete and accurate for 4 residents, (#40, #30, #2 and #268) out of total of 20 sampled Residents. Specifically: 1. For Resident #40, the facility failed to accurately document an order and implementation related to oxygen use. 2. For Resident #30 the facility inaccurately documented that they took blood pressures on the correct arm. 3. For Resident #2, the facility inaccurately documented that they applied both seizure pads in the Resident's bed. 4. For Resident #268, the facility inaccurately documented that the air mattress settings were set correctly.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff implemented abuse policies and procedures for one Resident (#28) out of a total of 20 sampled Residents. Specifically, for Resident #28 staff failed notify facility administration of an accusation that a Certified Nurse's Aide (CNA) wrapped a remote cord around his/her neck.

Inspectors wroteBased on record review and interview, the facility failed to report an incident of resident to resident abuse to the state agency for one Resident (#11) out of a total sample of 20 residents.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an injury of uknown origin for one Resident (#18) out of a total sample of 21 residents. Specifically, Resident #18 was found to have a dislocated shoulder and the facility interviewed the staff on the morning shift of the incident, but no other staff that had taken care of Resident #18.

Inspectors wroteBased on interviews and record review, for one of two sampled discharge residents (Resident #67), the facility failed to permit Resident #67 to return following an evaluation in the emergency department (ED) when on 02/10/25, the Facility considered Resident #67 discharged at the time of the transfer.

Inspectors wroteBased on record review and interview, the facility failed to update the plan of care after an incident of physical abuse for one Resident (#11) out of a total sample of 20 residents.

Inspectors wroteBased on record review and interview, the facility failed to follow a physician's order for air mattress settings for three Residents (#49, #17 and #268) out of a total sample of 20 residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure three residents (#58, #17, and #2) were free from accidents and hazards including elopement and failed to ensure the appropriate interventions were implemented for safety. Specifically, 1. For Resident #58, the facility to a. prevent an elopement from a secured unit and b. perform a thorough investigation 2. For Resident #17, the facility failed to implement a falls intervention 3. For Resident #2, the facility failed to apply seizure pads to bilateral side rails as ordered

Inspectors wroteBased on record review and interview, the facility failed to ensure specialized rehab services were provided in a timely fashion for one Resident (#28) out of a total sample of 20 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically the facility failed to: 1. Ensure that nursing performed hand hygiene (HH) and changed a wound dressing in accordance of professional standards to prevent infection. 2. Ensure the nurse did not touch medications while dispensing. 3. Ensure personal protective equipment (PPE) was readily available to staff when needed. 4. For Resident #40, the facility failed to implement contact precautions after he/she developed symptoms and tested positive for Clostridioides difficile (C-Diff; a bacterium that causes an infection of the colon, the longest part of the large intestine).

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure 1) medication rooms on two of two units were locked and secured while not in use and 2) medications were opened and dated on 2 of 3 sampled medication carts.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure food was stored and the kitchen was maintained, in accordance with professional standards for food service safety to prevent possible foodborne illness.

Inspectors wroteBased on observations, record review and interview the facility failed to ensure a reach in freezer containing food for preperation in the facility's main kitchen, was in a safe operable condition, ensuring that frozen food was frozen solid.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff respected resident room privacy for one Resident (#15) out of a total of 16 sampled residents.

Inspectors wroteBased on observation, record review and interview the facility failed for one Resident (#58), out of a total sample of 16 residents, to remain free from a potential restraint. Specifically, the facility failed to identify and assess the use of a specialized low chair used by Resident #58 as a potential restraint.

Inspectors wroteBased on observations, record review, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#41), out of a total sample of 16 residents. Specifically, for Resident #41 the facility failed ensure nursing completed a PICC line dressing change as ordered by the physician on 4/18/24 and nursing failed to ensure the PICC line dressing allowed nursing to observe the insertion site (insertion site was covered by a 2x2 gauze pad).

Inspectors wroteBased on interview, record and policy review and observation for one Resident (#21) of 16 sampled residents, the facility failed to clean the oxygen concentrator filters resulting in a thick layer of dust.

Inspectors wroteBased on interview, record and policy review and observation for one Resident (#21) of 16 sampled residents, the facility failed to accurately document cleaning of the oxygen concentrator filters.

Inspectors wroteBased on record review and interview the facility staff failed to inform two out of three residents reviewed, or their representatives with potential liability for payment for non-covered services including estimated cost of services.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, was known to wander and put objects in his/her mouth, the Facility failed to ensure that he/she was provided with an adequate level of staff supervision and an environment that was free from safety hazards, when on 03/29/24 nursing staff failed to secure medications delivered from the pharmacy, left them unattended at the Nurses' Station, and Resident #1 gained accessed to and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. Resident #1 was transferred to the Hospital Emergency Department for evaluation and monitoring, later that evening he/she required intubation and admission to the Hospital Intensive Care Unit.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was known to wander, rummage, and eat food he/she found, the Facility failed to ensure that medications were kept locked up (secured) or under direct supervision of nursing staff, when on 03/29/24, Nurse #1 left a medication package delivered from the Pharmacy unattended on the desk at the Nurses' Station, and as a result, Resident #1 was later found with the opened package and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. Resident #1 was transferred to the Hospital Emergency Department for evaluation and monitoring, and later required intubation and admission to the Hospital Intensive Care Unit.

Inspectors wroteBased on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3), who had diagnoses that included dysphagia (difficulty swallowing), the Facility failed to ensure they maintained accurate medical records related to the level of care and assistance they required from staff, when Certified Nurse Aide (CNA) documentation on Activity of Daily Living (ADL) Flowsheets for level of assistance provided to the residents for eating was inconsistent, inaccurate and/or incomplete (left blank). Findings Include: 1)Resident #1 was admitted to the Facility in April 2019, diagnoses included traumatic brain injury, dysphagia, aphasia, cerebral palsy, hypotension, bradycardia, bipolar disorder, and anxiety disorder. [...]