A list of the most recent deficiencies for The Royal Home. 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 fully informed and understand their health status, care and treatments. | Health | 2023-12-15 | 2024-01-17 | 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 | 2023-12-15 | 2024-01-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-15 | 2024-01-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-15 | 2024-01-17 | 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 | 2023-12-15 | 2024-01-17 | 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 | 2023-12-15 | 2024-01-17 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-12-15 | 2024-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-15 | 2024-01-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-15 | 2024-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-15 | 2024-01-17 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-12-15 | 2024-01-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-12-15 | 2024-01-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Meet fire sprinkler requirement for tall buildings. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-19 | 2024-01-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-27 | 2022-08-30 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-14 | 2022-04-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-02-14 | 2022-04-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-14 | 2022-04-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-14 | 2022-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-14 | 2022-04-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-14 | 2022-04-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-11 | 2022-02-24 | 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 | 2022-02-11 | 2022-02-24 | N |
| Provide or obtain dental services for each resident. | Health | 2022-02-11 | 2022-02-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-02-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-11 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-02-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-11 | 2022-02-24 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-02-11 | 2022-02-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-11 | 2022-02-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-11 | 2022-01-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-11 | 2022-01-28 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-03 | 2019-10-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-03 | 2019-10-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-03 | 2019-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-03 | 2019-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-03 | 2019-10-28 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2019-09-03 | 2019-10-28 | 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 | 2019-08-27 | 2019-10-03 | N |
| Post nurse staffing information every day. | Health | 2019-08-27 | 2019-10-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-27 | 2019-10-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-27 | 2019-10-03 | 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 | 2019-08-27 | 2019-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-27 | 2019-10-03 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-08-27 | 2019-10-03 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-08-27 | 2019-10-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-27 | 2019-10-03 | N |
