Royale Gardens Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Royale Gardens Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF755Oct 29, 2024

  Based on interview and record review it was determined the facility failed to provide timely pharmaceutical services for 3 of 7 sampled residents (#s 198, 21, and 78) reviewed for medication administration, and failed to ensure narcotic medication management systems were in place to account for and reconcile narcotics for 2 of 5 narcotic books reviewed for medication administration. This placed residents at risk for untimely medications and diversion. Findings include: 1. Resident 198 admitted to the facility in 10/11/24 with a history of seizures. The 10/2024 MAR instructed staff to administer lacosamide (antiseizure medication) two times a day for seizures, with a start date of 10/11/24. From 10/11/24 through 10/21/24 the MAR referred the reader to progress notes. […]

• Actual harm, isolatedF760Mar 13, 2026

  Based on interview and record review it was determined the facility failed to administer antibiotics for 1 of 1 sampled resident (#78) reviewed for hospitalization. As a result, Resident 78 was admitted to the hospital with a diagnosis of UTI. Findings include: Resident 78 was admitted to the facility in 1/2026 with a diagnosis of cancer. Resident 78's Progress Notes revealed the following:-1/6/26 Resident 78 had yellow/pink tinged urine in her/his Foley catheter drainage bag. Orders were received to hold Resident 78's blood thinner and blood work was to be obtained. -1/7/26 Resident 78's physician History and Physical Note revealed Resident 78 had cancer, and Resident 78 reported she/he hoped to live one year so she/he could return home. […]

• Actual harm, isolatedF686Oct 29, 2024

  Based on interview and record review it was determined the facility failed to accurately assess, care plan, implement, follow and maintain pressure ulcer treatments and care plans for 1 of 1 sampled resident (#191) reviewed for pressure ulcers. Resident 191 developing an avoidable unstageable (obscured full-thickness skin and tissue loss) pressure ulcer. Findings include: Resident 191 admitted to the facility in 6/2024 with diagnoses including kidney failure. The 6/17/24 Admission MDS indicated Resident 191 had pressure ulcer and was at risk for pressure ulcers due to incontinence and decreased mobility. Resident 191 admitted with a Stage 2 (shallow open wound) pressure ulcer to the coccyx. […]

• Actual harm, isolatedF603Jan 25, 2024

  Based on interviews and record review it was determined the facility failed to protect the resident's right to be free from involuntary seclusion by facility administration for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home. Findings include: Resident 12 was admitted to the facility in 11/2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part) and a history of traumatic brain… […]

• Actual harm, isolatedF604Jan 25, 2024

  Based on interviews, and record review it was determined the facility failed to protect the resident's right to be free from physical restraints for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home. Findings include: Resident 12 was admitted to the facility in 2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part), and a history of traumatic brain injury. […]