A list of the most recent deficiencies for Royal Gardens 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-20 | 2024-01-27 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-20 | 2024-01-27 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-12-20 | 2024-01-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-10 | 2024-01-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-10 | 2024-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-10 | 2024-01-02 | 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 | 2023-12-10 | 2024-01-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-10 | 2024-01-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-10 | 2024-01-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-10 | 2024-01-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-10 | 2024-01-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-10 | 2024-01-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-10 | 2024-01-02 | 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 | 2023-12-10 | 2024-01-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-10 | 2024-01-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-10 | 2024-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-10 | 2024-01-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-10 | 2024-01-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-10 | 2024-01-02 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-12-10 | 2024-01-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-12-13 | 2023-12-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-12-13 | 2023-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-13 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-13 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-13 | 2023-12-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-17 | 2023-08-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-19 | 2023-06-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-04 | 2023-04-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-02 | 2023-01-05 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-02 | 2023-01-05 | 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 | 2022-12-02 | 2023-01-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-02 | 2023-01-05 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2023-01-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-12-02 | 2023-01-05 | 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 | 2022-12-02 | 2023-01-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-02 | 2023-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-02 | 2023-01-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-02 | 2023-01-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-30 | 2022-12-20 | 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 | 2022-11-30 | 2022-12-20 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-11-30 | 2022-12-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-30 | 2022-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-30 | 2022-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-30 | 2022-12-20 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2022-11-30 | 2022-12-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-23 | 2022-09-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-12 | 2022-08-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-17 | 2022-08-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-31 | 2022-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-27 | 2022-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-03 | 2022-06-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-16 | 2022-05-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-11 | 2021-05-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-11 | 2021-05-20 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-07-29 | 2019-09-10 | 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 | 2019-07-29 | 2019-09-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-29 | 2019-09-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-19 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-19 | 2019-08-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-07-19 | 2019-08-16 | 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 | 2019-07-19 | 2019-08-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-19 | 2019-08-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-19 | 2019-08-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-07-19 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-19 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-19 | 2019-08-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-19 | 2019-08-16 | N |
| Keep all essential equipment working safely. | Health | 2019-07-19 | 2019-08-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-07-19 | 2019-08-16 | N |
