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Deficiency Records for Royalton Manor, L L C
A list of the most recent deficiencies for Royalton Manor, L L C. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Royalton Manor, L L C. 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? |
|---|---|---|---|---|
| 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 | 2024-08-01 | 2024-09-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-01 | 2024-09-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-01 | 2024-09-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-01 | 2024-09-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-01 | 2024-09-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-01 | 2024-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-06 | 2024-07-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-03 | 2024-04-29 | N |
| Provide activities to meet all resident's needs. | Health | 2024-04-03 | 2024-04-29 | 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 | 2024-04-03 | 2024-04-29 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-04-03 | 2024-04-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-03 | 2024-04-29 | 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 | 2024-04-03 | 2024-04-29 | 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 | 2024-04-03 | 2024-04-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-03 | 2024-04-29 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-04-03 | 2024-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-03 | 2024-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-03 | 2024-04-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-04-03 | 2024-04-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-04-03 | 2024-04-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-03 | 2024-04-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-03 | 2024-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-03 | 2024-04-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-03 | 2024-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-03 | 2024-04-29 | 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 | 2024-04-03 | 2024-04-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-03 | 2024-04-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-27 | 2024-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-27 | 2024-04-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-27 | 2024-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-27 | 2024-04-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-05 | 2023-04-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-05 | 2023-04-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-05 | 2023-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-04-18 | 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 | 2023-04-05 | 2023-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-05 | 2023-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-04-18 | 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 | 2023-04-04 | 2023-04-18 | 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 | 2023-04-04 | 2023-04-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-04 | 2023-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-04 | 2023-04-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-04-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-04 | 2023-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-04 | 2023-04-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-09 | 2023-04-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-09 | 2023-03-08 | Y |
| 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 | 2023-02-09 | 2023-03-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-09 | 2023-03-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-09 | 2023-03-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-09 | 2023-03-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-09 | 2023-03-08 | Y |
| 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 | 2023-02-09 | 2023-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-09 | 2023-03-08 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-02-09 | 2023-03-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-09 | 2023-03-08 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-09 | 2023-03-08 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-15 | 2022-08-03 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-15 | 2022-07-20 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-15 | 2022-07-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-07 | 2022-06-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-07 | 2022-06-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-07 | 2022-06-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-20 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-16 | 2022-03-02 | 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 | 2021-12-16 | 2022-02-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-16 | 2022-02-02 | 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 | 2021-12-16 | 2022-02-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-16 | 2022-02-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-16 | 2022-02-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-16 | 2022-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-16 | 2022-02-02 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-12-20 | 2022-01-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-20 | 2022-01-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-12-20 | 2022-01-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-20 | 2022-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-20 | 2022-01-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-20 | 2022-01-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-20 | 2022-01-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-20 | 2022-01-29 | 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 | 2021-12-20 | 2022-01-29 | 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 | 2021-12-20 | 2022-01-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-12-20 | 2022-01-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-20 | 2022-01-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-01-29 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-20 | 2022-01-29 | 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 | 2021-12-20 | 2022-01-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-20 | 2022-01-29 | Y |
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