Deficiency Records for Royal Norwell Nursing and Rehabilitation Center LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Royal Norwell Nursing and Rehabilitation Center LLC. 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? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-09-14 | 2023-10-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-14 | 2023-10-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-14 | 2023-10-23 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-14 | 2023-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-23 | 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 | 2023-09-14 | 2023-10-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-14 | 2023-10-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-14 | 2023-09-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-14 | 2023-09-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-14 | 2023-09-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-14 | 2023-09-26 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-09-14 | 2023-09-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-14 | 2023-09-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-14 | 2023-09-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-14 | 2023-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-09-19 | 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 | 2023-09-14 | 2023-09-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-14 | 2023-09-19 | 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 | 2023-09-14 | 2023-09-19 | 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 | 2023-09-14 | 2023-09-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-14 | 2023-09-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-14 | 2023-09-19 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-09-14 | 2023-09-19 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-09-14 | 2023-09-19 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-09-14 | 2023-09-19 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-09-14 | 2023-09-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-14 | 2023-09-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-14 | 2023-09-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-13 | 2023-08-05 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-07-12 | 2022-08-05 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-04 | 2021-06-11 | 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 | 2021-04-28 | 2021-06-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-04-28 | 2021-06-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-28 | 2021-06-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-28 | 2021-06-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-28 | 2021-06-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-06-01 | 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 | 2021-04-28 | 2021-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-28 | 2021-06-01 | N |
| Post nurse staffing information every day. | Health | 2021-04-28 | 2021-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-28 | 2021-06-01 | 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 | 2021-04-28 | 2021-06-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-04-28 | 2021-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-06-01 | N |
| Report COVID19 data to residents and families. | Health | 2021-04-28 | 2021-06-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-28 | 2021-06-01 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2021-04-28 | 2021-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-04 | 2021-05-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-04 | 2021-05-28 | 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 | 2021-05-04 | 2021-05-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-04 | 2021-05-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-04 | 2021-05-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-04 | 2021-05-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-05-04 | 2021-05-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-08 | 2019-12-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-08 | 2019-12-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-08 | 2019-11-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-10-08 | 2019-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-08 | 2019-10-18 | 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 | 2019-10-08 | 2019-10-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-08 | 2019-10-16 | 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 | 2019-10-08 | 2019-10-14 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-10-08 | 2019-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-08 | 2019-10-10 | N |
| 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 | 2019-10-08 | 2019-10-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-08 | 2019-10-08 | 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 | 2019-10-08 | 2019-10-08 | N |
