Avenues at Royal Oak

In the surveyor’s words

From the most serious findings on record at Avenues at Royal Oak, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Feb 14, 2024

  Based on observation, interview, and record review the administration failed to develop behavior management policies; failed to perform resident background checks within 24 hours of admission; failed to follow the facility's Identified Offender Policy and Procedure resulting in residents with a history of qualifying identified offender criminal conviction offenses being admitted to the facility for treatment for mental health services, without having an adequate amount of staff or adequate staff training on managing mental health disorders and behaviors, without care planning or acquiring specialized needs services as documented on those residents' PASRR (Pre-Admission Screening and Resident Review) Level II screenings and their pre-admission screenings; failed to ensure resident… […]

• Immediate jeopardy, widespreadF610Sep 13, 2023

  Based on observation, interview, and record review the facility failed to remove an alleged perpetrator V4 (Certified Nursing Assistant) from resident cares following staff (V4) to resident verbal abuse, failed to protect residents from an alleged abuser (V4), and failed to recognize verbal abuse for one of three residents (R1) reviewed for abuse in the sample of three. These failures resulted in V4 returning to work with all residents within the facility after verbally abusing R1, resulting in R1 feeling angry and experiencing fear. These failures have the potential to affect all 134 residents residing within the facility. These failures resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, patternF607Feb 14, 2024

  Based on observation, interview, and record review the facility failed to implement their Abuse policy by failing to protect multiple residents from verbal, physical, and mental abuse from another resident (R2), failing to provide adequate supervision of (R2) to prevent (R2) from further abusing other residents, failing to investigate and report to the state surveying agency multiple reports of resident-to-resident abuse, failed to thoroughly investigate resident-to resident abuse allegations, and failing to notify the police of resident-to-resident abuse for three of four residents (R1, R3, and R5) reviewed for abuse in the sample of 76. […]

• Immediate jeopardy, isolatedF689Apr 30, 2026

  Based on observation, interview and record review the facility failed to supervise a resident at high risk for elopement while on a 1:1 monitoring. This failure resulted in R4 leaving the facility unauthorized, and fracturing her foot while climbing/jumping over a fence. This failure applies to 1 of 3 residents reviewed for safety and supervision. The immediate Jeopardy began on 3/14/26 when V13 Certified Nursing Assistant (CNA) allowed R4 to shut her door and remain out of her line of vision while on a 1:1 monitoring status, allowing R4 to elope out of her window. V2 Administrator in Training was notified of the Immediate Jeopardy on 4/30/26 at 9:00 AM. […]

• Immediate jeopardy, isolatedF600Feb 14, 2024

  Based on observation, record review, and interview the facility failed to protect residents (R1, R3, R5) from verbal, mental, and physical abuse from another resident (R2) for three of four residents (R1, R3, R5) reviewed for abuse in the sample of 76. This failure resulted in R2 spitting on R1 on multiple occasions, pouring water over R1's head, cursing at R1 on multiple occasions days before R2 physically assaulted R1 by kicking and stomping R1 in the face which resulted in R1 sustaining lacerations to the nose and left eyelid, head trauma, bruising around the left eye, a hematoma under the left eye, severe pain, and mental anguish that required emergency room care for treatment. These failures resulted in an Immediate Jeopardy. […]