Royale Gardens Health & Rehabilitation Center

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a safe discharge for 1 of 3 sampled residents (#2) reviewed for unsafe discharge. This placed residents at risk for the lack of a safe and orderly discharge.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#2) reviewed for unsafe discharge. This placed residents at risk for unsafe discharges.

Inspectors wroteBased on interview and record review it was determined the facility failed to administer antibiotics for 1 of 1 sampled resident (#78) reviewed for hospitalization. As a result, Resident 78 was admitted to the hospital with a diagnosis of UTI.

Inspectors wroteBased on observation it was determined the facility failed to ensure the kitchen was kept in a sanitary manner in 1 of 1 kitchen reviewed for food service. This placed residents at risk for foodborne illness.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure their call light communication system functioned independently for each resident in a shared room for 4 of 4 sampled residents (#s 14, 22, 61, and 68) reviewed for call lights. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident and resident representative were included in the care planning process for 1 of 3 sampled residents (#5) reviewed for care planning. This placed residents at risk for insufficient involvement in care decisions.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed to self-administer medications for 1 of 4 sampled residents (#10) reviewed for accidents. This placed residents at risk for an adverse medication regimen.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received showers for 1 of 4 sampled residents (#36) reviewed for ADLs. This placed residents at risk for poor hygiene.

Inspectors wroteBased on observation, interview, and record it was determined the facility failed to provide meaningful activities for a dependent resident for 1 of 2 sampled residents (#5) reviewed for activities. This place residents at risk for lack of social interaction and isolation.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate ROM services for 2 of 3 sampled residents (#s 5 and 45) reviewed for position and mobility. This placed residents at risk for compromised mobility and pain.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure x-rays were obtained timely for 1 of 6 sampled residents (#10) reviewed for accidents. This placed residents at risk for delayed treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's clinical record accurately reflected the resident's resuscitation wishes for 1 of 4 sampled residents (#44) reviewed for ADLs. This placed residents at risk for not having their resuscitation choices followed.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure drinks were stored in accordance with professional standards for 1 of 2 resident refrigerators and failed to ensure water dispensers were properly sanitized for 1 of 1 water dispensers observed. This placed residents at risk for cross-contamination.

Inspectors wroteBased on interview and record review, it was determined the facility failed to inform the resident prior to the initiation of a psychotropic medication for 1 of 3 sampled residents (#3). This placed residents at risk for not being informed of the side effects of a medication and not participating in their treatment.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sampled residents (# 6) reviewed for abuse. This placed residents at risk for mental anguish and abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure sufficient nursing staff to ensure timely incontinent care and resident showers were completed for 6 of 6 sampled residents (#s 5, 8, 12, 14, 15, and 16) reviewed for staffing. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interviews and record review, it was determined the facility failed to treat, assess, and monitor wounds for 3 of 3 sampled residents (#s 101, 102, and 103) reviewed for wound care. This placed residents at risk for worsening wounds and infections.

Inspectors wroteBased on interview and record review it was determined the facility failed to assess the effectiveness of interventions and provide adequate resident supervision to prevent falls for 1 of 3 sampled residents (#s 102) reviewed for accidents. This placed residents at risk for recurring falls.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a sanitary kitchen environment for 1 of 1 facility kitchen. This placed residents at risk for food-borne illness.

Inspectors wrote3. Resident 52 admitted to the facility in 9/2023 with a diagnosis of diabetes. A 9/10/23 admission MDS revealed Resident 52 was cognitively intact but was not assessed for activity preferences. Resident 52 was identified to be at risk for social isolation, depression, and had blindness to both eyes. The assessment also indicated Resident 52 preferred to visit with her/his significant other. Activities/Recreation reviews revealed the following: -12/23/23 Resident 52 participated in 1:1 activities and her/his favorite activity was smoking outside with others. There was no identified activity goal or focus. -3/13/24 Resident 52 participated in 1:1 activities and enjoyed to smoke with others. There was no identified goals or focus. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to administer bowel care and follow therapy recommendations for 3 of 5 sampled residents (#s 30, 70 and 191) reviewed for pressure ulcers, and unnecessary medications. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a plan of care was reviewed and signed by a physician for 4 of 4 sampled residents (#s 2, 29, 31, and 35) reviewed for physician orders. This placed residents at risk for unassessed medical needs and adverse side effects of medication. Findings Include: 1. Resident 2 admitted to the facility in 9/2021 with diagnoses including arthritis and heart disease. During a review of Resident 2's clinical record on 10/28/24, a physician signed plan of care was not found for 1/2023 through 12/2023, 1/2024 through 3/2024, 5/2024, and 6/2024. On 10/28/24 at 4:00 PM Staff 1 (Administrator) and Staff 52 (Regional Director of Clinical Services) stated no further physician signed plans of care were available, and acknowledged the months without physician signed plans of care in Resident 2's clinical record. 2. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were seen by a physician every 60 days for 4 of 4 sampled residents (#s 2, 29, 31, and 35) reviewed for physician visits. This placed residents at risk for unmet medical needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a medication error rate of less than 5 percent. There were five errors out of 44 medication administration opportunities resulting in a 11.36 percent error rate. This placed residents at risk for an ineffective medication regimen.

Inspectors wroteBased on interview and record review it was determined the facility failed to accommodate resident needs for 1 of 6 sampled residents ( #49) reviewed for environment and speech. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents' grievances were addressed for 2 of 2 sampled residents (#s 52 and 70) reviewed for personal property. This placed residents at risk for unresolved grievances.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a report of misappropriation was reported to the State Survey Agency for 1 of 2 sampled residents (#52) reviewed for personal property. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was referred to the state agency authority for Level II PASARR (preadmission screening and resident review: assessment to ensure individuals with serious mental illness) evaluation for 1 of 1 sampled resident (#52) reviewed for PASARR. This placed residents at risk for lack of mental health services.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure baseline care plans were developed for 2 of 9 sampled residents (#s 24 and 243) reviewed for accidents and discharge. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to involve residents and/or representatives in the care planning process for 1 of 2 sampled residents (#8) reviewed for care plans. This placed residents at risk for lack of care plan interventions.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 5 sampled residents (#s 31 and 240) reviewed for ADLs. This placed resident at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess, care plan, implement, follow and maintain pressure ulcer treatments and care plans for 1 of 1 sampled resident (#191) reviewed for pressure ulcers. Resident 191 developing an avoidable unstageable (obscured full-thickness skin and tissue loss) pressure ulcer.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident received trauma informed care for 1 of 1 sampled resident (52) reviewed for behavioral-emotional care. This placed residents at risk for re-traumatization.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 1 of 5 sampled CNA staff (#35) reviewed for staffing. This placed residents at risk for a lack of competent staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely pharmaceutical services for 3 of 7 sampled residents (#s 198, 21, and 78) reviewed for medication administration, and failed to ensure narcotic medication management systems were in place to account for and reconcile narcotics for 2 of 5 narcotic books reviewed for medication administration. This placed residents at risk for untimely medications and diversion.

Inspectors wroteBased on interview and record review it was determined the facility failed to monitor a resident on a psychotropic medication for 1 of 5 sampled residents (#85) reviewed for medications. This placed residents at risk for receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident was provided dental services for 1 of 4 sampled residents (#30) reviewed for dental. This placed residents at risk for dental pain.

Inspectors wroteBased on observation, interview and record review it was determine the facility failed to follow modified textured diets as ordered for 1 of 6 sampled residents (#8) reviewed for food. This place residents at risk for medical complications and aspiration.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide assistive devices for 1 of 3 sampled residents (#15) reviewed for nutrition. This placed residents at risk for unmet dining needs.

Inspectors wroteBased on interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information.

Inspectors wroteBased on interviews and record review it was determined the facility failed to protect the resident's right to be free from involuntary seclusion by facility administration for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home.

Inspectors wroteBased on interviews, and record review it was determined the facility failed to protect the resident's right to be free from physical restraints for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home.

Inspectors wroteBased on interview and record review it was determined facility staff failed to provide necessary treatment and services to prevent pressure ulcers for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. Resident 6 developed an unstageable (wound covered by necrotic (dead) tissue or thick, brown or black scab or crust that covers the wound) ulcer on 12/20/23.

Inspectors wroteBased on interview and record review it was determined the facility failed to prevent a fall with significant injury for 1 of 3 sampled residents (#4) reviewed for falls and the facility failed to ensure appropriate mechanical lift equipment was available for transferring bariatric residents for 1 of 1 facility reviewed for accidents. The failure to prevent falls resulted in Resident 4 sustaining a fall with a fractured hip and required hospitalization. Both failures placed residents and staff at risk for falls and significant injuries.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain adequate room temperatures and a home like environment for 1 of 1 facility reviewed for comfortable and homelike environment. This placed residents at risk for an uncomfortable and un-homelike environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders, and failed to identify and address a resident's change of condition for 3 of 6 sampled residents (#s 2, 10 and 11) reviewed for physician orders and change of condition. This placed residents at risk for lack of care and treatment and negative medical outcomes related to delayed treatment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to monitor resident care equipment for 4 of 4 halls (A, B, F and G Halls) and failed to maintain kitchen equipment in a safe and functional condition for 1 of 1 kitchen reviewed for environment. This placed residents at risk for unmet needs, accidents, injury and food-borne illnesses.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a fall resulting in a serious bodily injury was reported to the State Agency for 1 of 3 sampled residents (#4) reviewed for falls. This placed residents at risk for abuse/neglect.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a thorough investigation regarding an injury of unknown origin for 4 of 4 sampled residents (#s 1, 2, 4 and 14) reviewed for safe environment and falls. This placed residents at risk for potential abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement the care plan for 1 of 3 sampled residents (# 12) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#3) reviewed for facility discharge. This placed residents at risk for an unsafe discharge.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide catheter care for 1 of 3 sampled residents (#12) reviewed for catheter care. This placed residents at risk for unmet catheter needs.

Inspectors wroteBased on observation, interview and record review it was determined facility staff failed to ensure professional standards were followed related to pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. Resident 1 developed a Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) pressure ulcer.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed provide necesssary treatment and services to prevent pressure ulcers for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developing a Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) pressure ulcer.

Inspectors wrote2. Resident 166 was admitted to the facility in 2023 with diagnoses including respiratory problems and pain. Resident 166's care plan dated 6/9/23 indicated she/he used smoking materials and the interventions were to instruct the resident on the facility policy for smoking, locations, times and safety. Resident 166's progress notes documented several incidents when the resident did not follow the smoking policy or left the facility to obtain beer. The care plan was not revised to indicate whether Resident 166 was an independent or supervised smoker, failed to comply with the facility's smoking policy or brought beer into the facility without a physician's order. On 7/14/23 at 12:01 PM Resident 166 was discussed with Staff 1 (Administrator) and Staff 2 (DNS). Staff 2 stated Resident 166 did not follow the smoking rules and was bringing beer into the facility without a physician's order. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 4 Halls (A, G & F Halls) and 1 of 1 dining room reviewed for staffing. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a qualified and trained IP in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a dignified dining experience for 1 of 2 sampled residents (#46) reviewed for dignity. This placed residents at risk for lack of dignity.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were included in care planning for 1 of 3 sampled residents (#18) reviewed for care planning. This placed residents at risk for not being involved in the care planning process.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess or assess timely for self-administration of medication for 2 of 6 sampled residents (#s 31 and 214) reviewed for medications. This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents' personal belongings were not searched without permission for 1 of 1 sampled resident (#166) reviewed for respect and dignity. This place residents at risk for lack of respect.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accommodate resident needs for 1 of 6 sampled residents (#21) reviewed for environment. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide bed hold information for 1 of 1 sampled resident (#61) reviewed for hospitalization. This placed residents at risk for lack of information related to the right to hold their bed placement while in the hospital.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement a care plan for catheters, anticoagulant medication and accidents for 1 of 9 sampled residents (#313) reviewed for medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement fall interventions and reevaluate a resident's smoking status for 2 of 4 sampled residents (#s 13 and 166) reviewed for accidents. This placed residents at risk for accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide respiratory care and services for 1 of 2 sampled residents (#49) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident food preferences were honored for 1 of 2 sampled residents (#314) reviewed for food. This placed residents at risk for lack of meal satisfaction and weight loss.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow infection control standards for 2 of 4 sampled residents (#s 49 & 214) reviewed for respiratory and urinary catheter. This placed residents at risk for exposure to and contraction of infectious diseases.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 27 and 29) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff.