Royal Oak Nursing & Rehab CTR

In the surveyor’s words

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

• Actual harm, isolatedF760Sep 16, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, manufacturer medication information, and interview the facility failed to ensure Resident #69 was free from significant medication error. Actual harm occurred on 07/29/24 when Resident #69 required evaluation and treatment in the emergency room due to a significant medication error of the resident's Topiramate (anti-epileptic/seizure medication). The resident had been administered, per the nurse practitioner, greater than three times the recommended dose of the medication (ordered 100 mg twice a day and received 625 mg twice a day) from 07/24/24 until 07/29/24 when the error was discovered. […]

• Actual harm, isolatedF689Feb 10, 2022

  Based on observation, record review, interview, and policy review the facility failed to ensure equipment was maintained and in good working condition to prevent a fall with injury for Resident #13. This affected one resident, Resident #13, of two residents reviewed for falls. The facility census was 78. Actual harm occurred on 01/28/21 when Resident #13 sustained a fall resulting in a neck fracture while being assisted by one State tested Nurse Assistant (STNA) during a shower in a shower bed. […]

• No harm, potential for more than minimal, widespreadF801Feb 10, 2022

  Based on record review and interview, the facility failed to ensure the dietary manager completed qualifications in a timely manner. This had the potential to affect all residents. The facility census was 78. Findings include: Review of the key personnel revealed Dietary Manager (DM) #610 as the kitchen director. Interview on 02/08/22 at 11:14 A.M. with DM #610 revealed she had worked for the facility for [AGE] years, seven as the dietary manager. DM #610 stated she was in the process of obtaining her certification as a dietary manager but had not started the classes. Interview on 02/08/22 at 12:24 P.M. with the Administrator verified DM #610 did not have the required qualifications and the Administrator was going to enroll DM #610 into classes to become a certified dietary manager. […]

• No harm, potential for more than minimal, widespreadF803Feb 10, 2022

  Based on review of the meal sheets, staff interview, resident interview, and review of the facility policy, the facility failed to ensure there were alternative menu choices with variety to meet resident preferences. This affected three residents (#16, #49, and #83) of four residents (#16, #49, #71, and #83) reviewed for food and had the potential to affect all residents. The facility census was 78. Findings include: Review of the medical record for Resident #83 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included [CONDITION(S)], hypertension ([CONDITION(S)]), mild protein-calorie malnutrition, and gastro-[CONDITION(S)] reflux disease (GERD). Review of physician orders for June 2021 identified orders for regular diet, regular texture, and regular consistency. […]

• No harm, potential for more than minimal, widespreadF812Feb 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff wore hair nets while in the kitchen and the 100 hall nursing unit refrigerator was maintained in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 78. Findings include: 1. Observation on 02/07/22 at 8:51 A.M. revealed Dietary Aide (DA) #796 scooping cooked ground beef out of a pot and into a steam table pan. DA #796 was not wearing a hairnet. Interview at the time of the observation with DA #796 verified DA #796 was not wearing a hair net. Observation on 02/08/22 at 2:02 P.M. revealed DA #904 washing her hands then retrieving serving utensils to puree food for the dinner meal. DA #904 was not wearing a hairnet. […]