A list of the most recent deficiencies for Royal Terrace Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2022-06-30 | 2022-07-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-17 | 2022-06-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-16 | 2022-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-11 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-09 | 2022-03-07 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-12-09 | 2022-03-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-21 | 2022-03-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-21 | 2022-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-21 | 2022-03-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-21 | 2022-03-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-21 | 2022-03-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-21 | 2022-03-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-01-21 | 2022-03-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-21 | 2022-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-03-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-20 | 2022-02-07 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-01-20 | 2022-02-07 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-01-20 | 2022-02-07 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-01-20 | 2022-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-20 | 2022-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-10 | 2022-01-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2022-01-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-12-10 | 2022-01-20 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-12-05 | 2020-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2020-02-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-05 | 2020-02-04 | N |
| Post nurse staffing information every day. | Health | 2019-12-05 | 2020-02-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-12-05 | 2020-02-04 | N |
| 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. | Health | 2019-12-05 | 2020-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-05 | 2020-02-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-02-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-05 | 2020-02-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-18 | 2020-01-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-18 | 2020-01-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-12-18 | 2020-01-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-12-18 | 2020-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-02 | 2018-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-02 | 2018-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-02 | 2018-12-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-02 | 2018-12-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-02 | 2018-12-20 | N |
| 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. | Health | 2018-12-02 | 2018-12-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-02 | 2018-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-02 | 2018-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-02 | 2018-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-12-02 | 2018-12-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-12-02 | 2018-12-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-12-02 | 2018-12-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-12-01 | 2018-12-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-12-01 | 2018-12-19 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-12-01 | 2018-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-01 | 2018-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-01 | 2018-12-19 | N |
