Royal Springs Healthcare and Rehab

In the surveyor’s words

From the most serious findings on record at Royal Springs Healthcare and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 29, 2024

  Based on interview, record review and document review, the facility failed to assess, re-assess, and adequately monitor a resident with a change in condition for 1 of 4 sampled residents (Resident 3). The deficient practice: 1) resulted in an acute physical decline that contributed to the resident's emergent transport to the hospital where the resident passed away, and 2) placed facility residents who had a change in condition at risk for poor clinical outcomes. Findings include: Resident 3 (R3) R3 admitted was admitted on [DATE] with diagnoses including chronic heart failure. […]

• Actual harm, isolatedF600Feb 21, 2023

  Based on observation, interview, record review, and document review, the facility failed to protect the resident's right to be free from neglect by providing timely incontinent care for 1 of 37 sampled residents (Resident #186). The failure to protect the resident rights from neglect places residents at risk to acquire Moisture Associated Skin Damage from being left wet in an incontinent brief for a long period of time when incontinent care was not provided timely. Findings include: Resident #186 (R186) R186 was admitted on [DATE], with diagnoses including sepsis, polyneuropathy, and obesity. The Quarterly Minimum Data Set assessment dated [DATE], documented R186 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated R186 was moderate impaired. […]

• No harm, potential for more than minimal, widespreadF812Mar 15, 2024

  Based on observation, interview, and document review, the facility failed to discard an expired food item and ensure 1 of 3 nourishment refrigerator temperatures were maintained. The deficient practice had the potential to place the residents at risk for a foodborne illness. Findings include: On [DATE] at 7:44 AM, an initial kitchen tour was conducted with the Dietary Director. On [DATE] at 8:01 AM, the walk-in refrigerator had 10 cartons of thickened dairy beverage with a best before date of [DATE]. The Dietary Director acknowledged the food item and best before date. On [DATE] at 8:30 AM, the Dietary Director indicated there were three nourishment refrigerators in the facility. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2023

  Based on observation, interview, and document review, the facility failed to ensure 1) opened food items were labeled and dated in kitchen, 2) expired food items were discarded, 3) staffs' personal food items and beverages were not in food preparation areas, 4) dishwasher chemical was properly dispensing, 5) the cleanliness of the kitchen and equipment, 6) walk-in freezer was free from ice build-up, 7) perishable butter was properly refrigerated, and 8) nourishment room food items in the refrigerator and freezer were labeled, dated, and expired items were discarded. The failure to label and date food items, maintain a clean and sanitary kitchen had the potential to serve foods to the residents at an increased risk of food safety. […]

• No harm, potential for more than minimal, widespreadF838Feb 21, 2023

  Based on interview and document review, the facility failed to review and update their facility assessment at least annually. The failure could result in the facility not being able to determine what resources were necessary to care for its residents competently. Findings include: The Facility Assessment indicated the document had been last reviewed and approved 10/2021. The Facility Assessment indicted it was the facility practice to review and update the document annually or with significant changes in facility operations. On 02/21/2023, in the morning, the Administrator explained the facility practice was to update the Assessment annually as part of the QAPI process. The Administrator verified the Assessment documented the last review and update was over one year prior. […]