Royal Oaks Nursing And Rehab Center

Based on observation, and interview, the facility failed to provide a homelike environment for all residents who ate their meals in the west wing dining area, by serving the resident's meals on serving trays at the table in an institutional manner.Findings:On 2/22/26 at 12:56 PM, during meal observation on the west wing, 5 residents were observed seated at the tables in the dining area. Each resident was noted to have a serving tray on the table in front of them which contained the lunch meal. The plates, cups, bowls and eating utensils remained on the tray and were not removed from the tray at the table.On 2/23/26 at 1:00 PM, during meal observation on the west wing, 7 residents were observed seated in the dining areas. Staff were observed as they served meals to residents on serving trays. Staff placed the trays on the table in front of each resident but did not remove items from the tray. A family member visiting one of the residents in the room was observed as she removed the items from the serving tray in front of the resident and placed them on the table in front of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 3 of 5 residents reviewed for choices out of a total sample of 34 residents, (#31, #55, #75).Findings 1Resident #31 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia, congestive heart failure and chronic kidney disease.Review of the medical record showed the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 1/16/26 revealed resident # 31 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact. The MDS also revealed that the resident's vision was adequate and she wore corrective lenses.Physician's orders included Refresh Tears Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophthalmic)) and nurses were directed to instill 2 drops in both eyes two times a day for dry eyes.On 2/22/26 at 12:19 PM, resident #31…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for removal of a central venous catheter for 1 of 2 residents reviewed for intravenous lines and for 1 of 2 residents reviewed for limited range of motion, of a total sample of 34 residents, ( #6,#70).Findings: 1.On 2/22/26 at 11:43 AM resident #6 was observed sitting in her wheelchair in her room. Resident was noted to have a single lumen midline to her right upper arm with a date of 2/20/26 on the dressing. Resident #6 was admitted to the facility on [DATE] with diagnoses including dislocation of internal right hip prosthesis, infection following a procedure, and non-pressure chronic ulcer. Review of Infectious Disease note 2/20/26 revealed that on 2/3/26 the resident was assessed and her left buttocks wound was noted to be red and a foul smell. An order was given for culture and sensitivity of left buttock wound which was positive for Proteus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to supervise a catheter drainage bag per infection control standards, to prevent contamination and the spread of infection for 1 of 1 resident reviewed for a bladder catheter of a sample of 34 residents. Findings:Resident #14 was admitted to the facility 1/30/26 with diagnoses of congestive heart failure, atrial fibrillation, urinary retention, peripheral vascular disease, right femoral embolism, & chronic kidney disease. On 2/22/26 at 10:35 AM, resident #14 was asleep in his chair, his catheter bag on the ground. At 12:12 PM he sat in his chair, and the urine collection bag was on the floor. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed that resident #14 was cognitively intact, used a walker with minimal supervision, and needed moderate assistance for activities of daily living. The resident's care plan from 12/20/25 contained a goal of decreased risk of signs and symptoms of a urinary tract infection (UTI) and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain food cooking equipment in a clean and sanitary manner to prevent physical contaminants that may inadvertently enter food eaten by the residents of the facility. Finding: On Sunday, 6/23/24, at 10:58 AM, the facility's kitchen was inspected with the facility cook. The deep fryer was not clean with food debris noted on the metal surfaces of the deep fryer. Inside the fryer itself, food debris particles were observed floating on top of the cooking oil, almost covering the entire surface. The cooking oil was very dark colored and appeared not to have been changed for some time. The cook verified the condition of the deep fryer and stated she had not used the deep fryer this morning and explained it was usually used for cooking chicken and french fries. When asked about the cleaning schedule for the cooking equipment, the cook said she did not know the last time the deep fryer had been cleaned or the cooking oil changed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a systematic approach to ensure residents were not over hydrated due to health conditions and followed physician ordered fluid restrictions to promote the highest practicable outcome for 1 of 3 residents reviewed for nutrition/hydration issues, of a total sample of 38 residents, (#5). Findings: On 6/24/24 resident #5 was observed in his room on the [NAME] Wing of the facility at approximately 1:34 PM. The resident was awake with some confusion and his wife was in the room with him. She explained her husband was incontinent and it took a long time for staff to change him. The resident's wife indicated her husband had not been in the facility very long and hoped he would return home. She expressed concern he was about to change rooms and be placed in a room on the East Wing where the staff were not familiar with her husband's care. Medical record review revealed resident #5's most recent admission to the facility on 6/09/24. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote dignity related to missing front teeth affecting the resident's self-esteem for 1 of 2 residents reviewed for dignity, out of a total sample of 52 residents, (#53). Findings: Resident #53 was admitted to the facility on [DATE] with diagnosis including polyneuropathy, and major depressive disorder. On 12/12/22 at 11:39 AM, resident #53 stated she lost her upper partial denture back in June, 6 months ago. She recalled she filed a grievance at that time and was told the facility would pay to have it replaced. She stated she had not seen a dentist and explained she had never been without teeth and really wanted to have the partial denture replaced. On 12/14/22 at 3:48 PM, resident #53 clarified it was the [NAME] Wing Unit Manager who told her the facility would pay to replace her partial denture. She noted she was unsure why it was taking so long to have the denture replaced. Resident #53 stated she had been a public speaker and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dental services in a timely manner for 1 of 2 residents reviewed for dental services, out of a total sample of 52 residents, (#53). Findings: Resident #53 was admitted to the facility on [DATE] with diagnoses of polyneuropathy, cardiac pacemaker and major depressive disorder. On 12/12/22 at 11:39 AM, resident #53 stated she lost her upper partial denture 6 months ago, in June. She recalled she filed a grievance at that time and was told the facility would pay to have it replaced. She stated she had not seen a dentist since that time and added she had never been without teeth and wanted to have the partial denture replaced. On 12/14/22 at 2:01 PM, the Social Services Assistant (SSA) confirmed a grievance was filed June 15, 2022. She stated she did not know what happened to resident #53's partial denture but a replacement was in the works. On 12/14/22 at 3:04 PM, the Social Services Director (SSD) stated when a resident reported…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline/interim care plans in a timely manner related to intravenous (IV) antibiotics and psychotropic medication use for 1 of 1 newly admitted resident reviewed for IV antibiotic therapy and mood/behavioral services of a total sample of 52 residents, (#311). Findings: Resident #311's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses of severe sepsis, alcohol induced pancreatitis, enterocolitis due to clostridium difficile toxin, pneumonia, and alcohol withdrawal delirium. Resident #311 was observed on 12/12/22 at 10:35 AM, lying in bed with his spouse sitting at the bedside. He was noted to have a right upper arm IV line with bag of antibiotics (Vancomycin) currently infusing via IV pump and empty bag IV antibiotics (Zosyn) hanging from pole. The wife said he had been on a lot of drugs to help manage his anxiety and agitation. On 12/13/22 at 3:40 PM, resident #311 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.