Royal Nursing Center, LLC

In the surveyor’s words

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

• Actual harm, isolatedF760Apr 8, 2025

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had severe cognitive impairment and was unable to identify him/herself, the Facility failed to ensure he/she was free from a significant medication error, when on 03/13/25, Resident #1 was administered another resident's medications in error. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, he/she remained in the Hospital overnight for monitoring and treatment to stabilize his/her blood pressure, which included administration of intravenous fluids and medications. […]

• No harm, potential for more than minimal, patternF804Dec 18, 2025

  Based on observations, interviews, and meal test tray results, the facility failed to serve meals that were palatable and at appetizing temperatures on one (Vineyard Sound) of three units.Using the reasonable person concept, a person would not find the food temperatures palatable and appetizing.Findings include:Review of the facility's Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on 12/16/25 indicated 36 out of 40 residents residing on the Vineyard Sound Unit had a diagnosis of Alzheimer's disease or dementia. […]

• No harm, potential for more than minimal, patternF679Jun 8, 2023

  Based on observations, interviews, and record review, the facility failed to provide one Resident (#21), out of a total sample of 18 residents, an activity program that engaged the Resident and supported their physical, mental, and psychosocial well-being. Findings include: Resident #21 was admitted to the facility in March 2023 with diagnoses which included diabetes mellitus, dementia, and cognitive-communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 4/29/23, indicated Resident #21 scored a 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. Review of the care plan for Resident #21 indicated: Focus of Activities - Long Term Care Resident indicated he/she needed encouragement and reminders. […]

• No harm, potential for more than minimal, patternF680Jun 8, 2023

  Based on document review and interview, the facility failed to ensure the activities program was directed by a qualified professional who has completed a state approved training course. Findings include: During an interview on 6/8/23 at 2:34 P.M., the Activity Director said she is newer to the role and still learning and trying to train the staff she supervises in the department. Review of the employee file for the Activity Director (AD) indicated the following: - she was offered and accepted the role of AD in November 2021 - she did not possess the completed training and qualifications of an AD - she signed a job description indicating she was the AD on 11/24/21 - she was offered and started a self-paced modular educational program to become a trained qualified AD in January 2023… […]

• No harm, potential for more than minimal, patternF690Jun 8, 2023

  Based on observation, record review, policy review, and interview, the facility failed for two Residents (#75 and #185), out of a total sample of 18 residents, to maintain professional standards in the managing and care for urinary catheter devices. Specifically, the facility failed: 1. For Resident #75, to ensure the drainage bag and tubing were positioned to lessen the likelihood of complications; and 2. For Resident #185, to maintain the catheter in a manner to prevent the possibility of infection. […]