Royal Wood Mill Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 9, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, was known to wander and put objects in his/her mouth, the Facility failed to ensure that he/she was provided with an adequate level of staff supervision and an environment that was free from safety hazards, when on 03/29/24 nursing staff failed to secure medications delivered from the pharmacy, left them unattended at the Nurses' Station, and Resident #1 gained accessed to and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. […]

• Actual harm, isolatedF761Apr 9, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was known to wander, rummage, and eat food he/she found, the Facility failed to ensure that medications were kept locked up (secured) or under direct supervision of nursing staff, when on 03/29/24, Nurse #1 left a medication package delivered from the Pharmacy unattended on the desk at the Nurses' Station, and as a result, Resident #1 was later found with the opened package and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. […]

• Actual harm, isolatedF688Mar 3, 2023

  Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion for 1 Resident (#30) out of a total sample of 21 residents. Findings include: Resident #30 was admitted to the facility in June 2022, with diagnoses hemiplegia (paralysis) of the left side. Review of Resident #30's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. On 3/2/23 at approximately 8:30 A.M., Resident #30 was observed sitting in his/her wheelchair. Resident #30's right foot was pointing towards the ground and inward. When asked, Resident #30 was unable to move his/her ankle. […]

• Actual harm, isolatedF689Mar 3, 2023

  Based on record review and interviews, the facility failed to 1) prevent 1 Resident (#9) from choking by providing the wrong diet and 2) failed to prevent 1 Resident (#26) from falling out of a total sample of 21 residents. Findings include: 1. Resident # 9 was admitted to the facility in March 2018, with diagnoses including dysphagia (difficulty swallowing) and dementia. Review of Resident #9's most recent Minimum Data Set, dated dated dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated he/she has moderate cognitive impairment. The MDS also indicates Resident #9 requires supervision for self-feeding at meals. […]

• Actual harm, isolatedF692Mar 3, 2023

  Based on observation, record review and interview the facility failed to identify a significant weight loss in a timely manner for 1 Resident (#23), out of a total sample of 21 residents. Findings include: Review of the facility policy titled; Weight Surveillance, undated, indicated the following: -Resident weights are an important indicator of nutritional status and overall health status. -Re-weights are to be obtained if there is a three-pound discrepancy from the previous weight. […]