Royal Megansett Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Royal Megansett Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658Nov 9, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Unit Manager #1 discontinued Resident #1's [MEDICATION(S)], without a valid and/or signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], Resident #1 exhibited signs and symptoms of a stroke, including slurred speech, left sided facial weakness when smiling, and he/she was unable to hold up his/her left upper extremity. […]

• Immediate jeopardy, isolatedF760Nov 9, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When on [DATE], Unit Manager #1 discontinued Resident #1's [MEDICATION(S)] (an anticoagulant medication), without a valid and signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #1 exhibited signs and symptoms of a stroke including slurred speech, left sided facial weakness when smiling, and was unable to hold up his/her left upper extremity. […]

• Actual harm, isolatedF689Feb 7, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was at risk for falls, had severe cognitive impairment, required supervision with ambulation, and assistance of one staff member with toileting, the Facility failed ensure they provided adequate assistance and supervision to maintain a safe environment to prevent accidents and injuries. On 01/23/22, at 7:45 A.M., Resident #1 slipped on the wet floor (newly washed by housekeeping) in his/her room while ambulating barefoot, unsupervised, on his/her way out of the bathroom and fell on to his/her right wrist. […]

• No harm, potential for more than minimal, patternF686Apr 8, 2025

  Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#56), out of 17 sampled residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed to implement a treatment that included an antimicrobial wash to a Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the sacrum (bone located at the base of the spine). Findings include: Resident #56 was admitted to the facility in December 2024 with diagnoses which included pressure ulcer of sacral region. […]

• No harm, potential for more than minimal, patternF755May 24, 2024

  Based on observation, interview, document review, and policy review, the facility failed to ensure an accurate account of all controlled medications was maintained. Specifically, the facility failed to ensure an accurate account of lorazepam (Ativan) (schedule IV-controlled drug with low potential for abuse, treats anxiety) oral concentrate was maintained in the controlled substance accountability record book, as required. Findings include: Review of the facility's policy titled Controlled Substances, undated, indicated but was not limited to the following: -The facility shall comply with all laws, regulations, and other requirements related to the handling, storage, disposal, and documentation of Schedule II and other controlled substances. […]