Royal Oak Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF684Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure an assessment and documentation for discovered skin discolorations / bruising was performed for three (Residents #201, #6, and #19) of 22 sampled residents and failed to ensure wound dressings were dated and initialed for one (Resident #252) of 22 sampled residents. Findings included: 1. On 03/26/2024 at 9:15 a.m., Resident #201 was observed sitting in her wheelchair returning to her room from the shower. She was dressed and groomed for the day. Resident #201 had a dialysis catheter present in the left chest area. She had a urinary catheter. There was a discolored bruised area on her right upper arm. She stated it was from the IV (Intravenous line) at the hospital. She stated it was [NAME] and larger. […]

• No harm, potential for more than minimal, patternF880Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure infection control practices and procedures were followed during medication administration for four (Residents #260, #259, #13 and #35) of seven sampled residents and one (Resident #84) of one sampled resident related to proper storing of a nebulizer mask. Findings included: 1. On 03/26/2024 at 8:35 a.m., Staff B, Licensed Practical Nurse (LPN) was observed passing medications to Resident #260. Staff B, LPN failed to perform hand hygiene after passing the medications. 2. On 03/26/2024 at 9:30 a.m., Staff B, LPN and the Regional Registered Nurse (RN) were observed passing medications to Resident #259 via a gastrostomy tube. […]

• No harm, potential for more than minimal, patternF677Jan 14, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure assistance with Activities of Daily Living (ADL) for dependent residents was provided for six (Resident #17, #26, #27, #21, and #78) of 33 sampled residents. Findings included: A review of Resident #17's Medical Record revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #17's Care Plan revealed a problem, revised on 01/14/2022, that she had poor intake by mouth and was at risk for weight loss/dehydration. Interventions included to provide super foods as indicated, provide diet per order, and provide a home made chocolate milkshake two times daily. […]

• No harm, potential for more than minimal, patternF759Jan 14, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than 5%. A total of 34 administration opportunities were observed with 16 medication errors for three (Resident #70, Resident #72, and Resident #240) of six residents observed for medication administration, resulting in a medication administration error rate of 47.06%. Findings included: A review of Resident #70's Medical Record revealed that Resident #70 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF880Feb 2, 2026

  Based on observations, interviews, and policy review, the facility failed to ensure isolation protocols were followed related to PPE (personal protection equipment) use and notifying visitors of infections, in two rooms (231 and 230) out of 15 rooms in hall 200.Findings included: On 02/02/2026 at 03:33 PM, room [ROOM NUMBER] was observed with a contact isolation sign on it, requiring gloves and a gown prior to room entry. There was no indication of whether the sign was for the resident in Bed A or the resident in Bed B. Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, were observed leaving room [ROOM NUMBER] B, without gloves and gowns after assisting a resident on Bed B's side, as the resident was in a wheelchair. […]