Deficiency Records for Royal Gardens Healthcare
Updated as of April 01, 2022
This is not the most recent data for Royal Gardens Healthcare. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-10-16 | 2021-02-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-04-21 | 2020-05-21 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-03-17 | 2020-04-08 | 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 other general requirements that are deficient. | 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-17 | 2019-06-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-03 | 2019-06-17 | 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 | 2019-06-03 | 2019-06-17 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2018-07-24 | 2018-09-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-24 | 2018-09-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-24 | 2018-09-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-24 | 2018-09-10 | 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 | 2018-07-24 | 2018-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-24 | 2018-09-10 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-07-24 | 2018-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-20 | 2018-08-31 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-20 | 2018-08-31 | 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 | 2018-07-20 | 2018-08-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-20 | 2018-08-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-07-20 | 2018-08-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-07-20 | 2018-08-31 | 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 | 2018-07-20 | 2018-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-20 | 2018-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-20 | 2018-08-31 | N |
| Keep all essential equipment working safely. | Health | 2018-07-20 | 2018-08-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-07-20 | 2018-08-31 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-22 | 2017-09-06 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-07-22 | 2017-09-06 | N |
| Provide housekeeping and maintenance services. | Health | 2017-07-22 | 2017-09-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-07-22 | 2017-09-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-22 | 2017-09-06 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-07-22 | 2017-09-06 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-07-22 | 2017-09-06 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-22 | 2017-09-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-22 | 2017-09-06 | N |
| Make sure that doctors visit residents regularly, as required. | Health | 2017-07-22 | 2017-09-06 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-22 | 2017-09-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-07-22 | 2017-09-06 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-07-22 | 2017-09-06 | N |
| Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. | Health | 2017-07-22 | 2017-09-06 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2017-07-22 | 2017-09-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-07-22 | 2017-08-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2017-07-22 | 2017-08-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-07-22 | 2017-08-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2017-07-22 | 2017-08-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2017-07-22 | 2017-08-14 | N |
