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Deficiency Records for Royal Springs Healthcare and Rehab
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.
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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-10-29 | 2024-12-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-29 | 2024-12-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-15 | 2024-04-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-03-15 | 2024-04-23 | 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 | 2024-03-15 | 2024-04-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-15 | 2024-04-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-15 | 2024-04-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-15 | 2024-04-10 | 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 | 2024-03-15 | 2024-04-10 | 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 | 2024-03-15 | 2024-04-10 | 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 | 2024-03-15 | 2024-04-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-15 | 2024-04-10 | 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 | 2024-03-15 | 2024-04-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-15 | 2024-04-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-15 | 2024-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-15 | 2024-04-10 | N |
| Keep all essential equipment working safely. | Health | 2024-03-15 | 2024-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-15 | 2024-04-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-21 | 2023-04-14 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Develop a communication plan. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Ensure gas and vacuum piping is labeled. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-21 | 2023-03-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-21 | 2023-03-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-21 | 2023-03-27 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-21 | 2023-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-21 | 2023-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-02-21 | 2023-03-27 | 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 | 2023-02-21 | 2023-03-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-02-21 | 2023-03-27 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-21 | 2023-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-21 | 2023-03-27 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-02-21 | 2023-03-27 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-02-21 | 2023-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-21 | 2023-03-27 | 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 | 2023-02-21 | 2023-03-27 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-21 | 2023-03-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-21 | 2023-03-27 | 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 | 2023-02-21 | 2023-03-27 | Y |
| 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 | 2023-02-21 | 2023-03-27 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-11-04 | 2022-12-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-04 | 2022-12-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-04 | 2022-12-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-04 | 2022-12-31 | Y |
| 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 | 2022-11-04 | 2022-12-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-04 | 2022-12-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-04 | 2022-09-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-27 | 2020-05-22 | 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 | 2020-02-27 | 2020-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-02-27 | 2020-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-11 | 2020-05-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-11 | 2020-05-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-03-11 | 2020-05-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-11 | 2020-05-18 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-11 | 2020-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-11 | 2020-05-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-03-11 | 2020-05-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-11 | 2020-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-11 | 2020-05-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-03-11 | 2020-05-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-11 | 2020-05-18 | N |
| Provide appropriate foot care. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-03-11 | 2020-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-11 | 2020-05-18 | N |
| Dispose of garbage and refuse properly. | Health | 2020-03-11 | 2020-05-18 | 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 | 2020-03-11 | 2020-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-11 | 2020-05-18 | N |
| Keep all essential equipment working safely. | Health | 2020-03-11 | 2020-05-18 | N |
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