Royal Meadow View Center

In the surveyor’s words

From the most serious findings on record at Royal Meadow View Center, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 28, 2022

  Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure Resident #1 was free from abuse when it was reported by two staff members that they witnessed Nurse #1, on two separate occasions, interact with Resident #1 in a verbally abusive and threatening manner. Findings include: Review of the Facility's Policy and Procedure titled, Abuse, Neglect, Misappropriation of Resident Property and Involuntary Seclusion, dated as revised on 1/09/2019, indicated each resident has the right to be free from abuse and must not be abused by anyone, including staff. Resident #1 was admitted to the Facility in July 2021. […]

• Actual harm, isolatedF607Apr 28, 2022

  Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure staff implemented and followed their Abuse Policy, when two staff members failed to immediately report allegations of verbal abuse to the Executive Director or designee. When during the course of a facility investigation it was determined that a staff member witnessed and failed to report an incident in which Nurse #1 verbally abused Resident #1, that had occurred in October 2021, therefore placing Resident #1 and other residents at risk for the potential to be abused. Approximately one month later, a second staff member witnessed Nurse #1 verbally abusing Resident #1, and also failed to immediately report the incident. […]

• Actual harm, isolatedF689Feb 17, 2022

  Based on record review and interview, the facility failed to provide supervision during a meal, resulting in a fall with injury for 1 Resident (#41) out of a total sample of 20 residents. Findings include: Resident # 41 was admitted to the facility in 10/19 with diagnoses including dementia, [CONDITION(S)] and dysphagia (trouble swallowing). Review of Resident #41's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS). […]

• Actual harm, isolatedF692Feb 17, 2022

  Based on observation, record review and interview, the facility failed to identify and address significant weight losses for 3 Residents (#36, #59 and #62) out of a total of 20 sampled residents. 1. Resident #36 was admitted in 02/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nutrition care plan for Resident #36 indicated the following: - Resident # 36 is at nutrition risk due to increased nutrition needs, inadequate oral intakes, unintentional weight loss due to [CONDITION(S)], picky eating, increased nutrition needs. […]

• Actual harm, isolatedF580Jul 28, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had been evaluated in the Hospital Emergency Department (ED) after a fall in the Facility, and was diagnosed with a contusion of his/her right elbow, the Facility failed to ensure nursing notified Resident #1's Physician to obtain orders to treat his/her pain. On 07/07/21, upon return from the ED, Resident #1 requested pain medication from Nurse #1 and was told by Nurse #1 he/she did not have any pain medications available, Resident #1 continued to request pain medication from Nurse #1 throughout the night, but was told he/she had no orders for pain medication. […]