Deficiency Records for Royal Springs Healthcare and Rehab
Updated as of May 01, 2019
This is not the most recent data for Royal Springs Healthcare and Rehab. For the most recent information, click here.
A list of the most recent deficiencies for Royal Springs Healthcare and Rehab. 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? |
|---|---|---|---|---|
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-10-12 | 2018-11-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-12 | 2018-11-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-10-12 | 2018-11-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-12 | 2018-11-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2018-10-12 | 2018-11-14 | Y |
| Provide or obtain dental services for each resident. | Health | 2018-05-25 | 2018-07-09 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-05-25 | 2018-07-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-21 | 2018-04-05 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-01-18 | 2018-03-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-01-18 | 2018-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-18 | 2018-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-18 | 2018-03-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-18 | 2018-03-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-01-18 | 2018-03-12 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2018-01-18 | 2018-03-12 | 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 | 2018-01-18 | 2018-02-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-01-18 | 2018-02-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-18 | 2018-02-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-01-18 | 2018-02-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-18 | 2018-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-18 | 2018-02-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-18 | 2018-02-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-01-12 | 2018-02-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-01-12 | 2018-02-26 | 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 | 2018-01-12 | 2018-02-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-01-12 | 2018-02-26 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-01-18 | 2018-02-12 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-01 | 2017-10-19 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-01-05 | 2017-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-05 | 2017-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-01-05 | 2017-01-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-01-05 | 2017-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-01-05 | 2017-01-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-01-05 | 2017-01-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2016-12-30 | 2017-01-31 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-30 | 2017-01-31 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-12-30 | 2017-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-30 | 2017-01-31 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-12-30 | 2017-01-31 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-30 | 2017-01-31 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-12-30 | 2017-01-31 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-22 | Not Fixed | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-22 | Not Fixed | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Develop a communication plan. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Ensure when modifications are made that breach pipelines, testing is conducted on downstream portions of the piping system. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-22 | Not Fixed | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-03-22 | Not Fixed | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-03-22 | Not Fixed | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-03-22 | Not Fixed | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-03-22 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-22 | Not Fixed | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-22 | Not Fixed | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-22 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-22 | Not Fixed | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-22 | Not Fixed | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-03-22 | Not Fixed | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-03-22 | Not Fixed | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-22 | Not Fixed | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-22 | Not Fixed | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | 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 | 2019-03-22 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-22 | Not Fixed | N |
