Royal Palms Post Acute

In the surveyor’s words

From the most serious findings on record at Royal Palms Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF806Feb 23, 2024

  Based on observation, interview and record review, the facility failed to ensure two (2) of two (2) sampled residents (Residents 285 and 131), who had food intolerances (food sensitivity and inability to digest a certain food) and food allergies (a serious and potentially life-threatening medical condition to substances that are usually not harmful) were assessed for food restrictions, including food allergies and served with food substitutions (replaced food with allergens with food without allergens) as indicated in the facility ' s policies and procedures titled, Food Allergies and Intolerances, and Nutrition Assessment, by failing to: 1. Ensure Cook 1 did not serve fish and fish containing products to Resident 285 and Resident 131, who were allergic to fish on [DATE]. […]

• Immediate jeopardy, isolatedF604Apr 17, 2024

  Based on interviews and record reviews, the facility failed to ensure one of two residents (Resident 1) was free from physical restraint (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) when Certified Nursing Assistant 1 (CNA 1) tied the resident with a bed sheet to the waist and around the wheelchair on 4/11/24. According to CNA 1, she tied down the resident down in the wheelchair with a bed sheet to prevent the resident from getting up while she was attending to another resident (Resident 2) This deficient practice resulted in Resident 1's rights being violated, and held against her will. […]

• Actual harm, isolatedF635Jan 11, 2023

  Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility's policies and procedure for one of three sampled residents (Resident 1), when it failed to: 1. Provide oversight to ensure all appropriate medical records that included treatments and other follow up discharge orders were provided to the facility prior to or upon the resident's admission to the facility as indicated in the facility's policy titled Admissions Policy. 2. […]

• Actual harm, isolatedF711Jan 11, 2023

  Based on interviews and record reviews, the facility failed to ensure the facility's attending physician (Physician 1) reviewed one of three residents' (Resident 1) total program of care, including reviewing the resident's medications and treatments while residing in the facility from 10/21/22 to 12/2/22 in accordance with the facility's policy and procedure (P&Ps), by failing to: 1. Review Resident 1's general acute care hospital (GACH 1) Discharge Documentation/Discharge Action Plan and Discharge Summary, that indicated the GACH 1's discharge orders upon admission to the facility on [DATE], to ensure continuity of care in the facility. 2. […]

• Actual harm, isolatedF600Jul 6, 2022

  Based on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from sexual abuse. Resident 1, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA 1 assisted Resident 1 during bathing in the facility's Shower Room on 6/13/2022 and 6/14/2022. CNA 1 stated that during the shower, Resident 1 was moaning and had an orgasm. This deficient practice resulted in Resident 1 to experience sexual abuse from CNA 1. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 6/12/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]