Royal Oaks Manor-Bradbury Oaks

In the surveyor’s words

From the most serious findings on record at Royal Oaks Manor-Bradbury Oaks, in the surveyor’s own words.

• Actual harm, isolatedF689May 10, 2024

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from the toilet to the wheelchair when CNA 1 used the Sara lift (mechanical lift, a device used by staff to transfer residents from one location to another e.g., a bed to a chair). 2. Ensure CNA 1 followed the facility's Policy and Procedures (P&P) titled, Lifting Machine, Using a Mechanical, and Fall & Fall Risk, Managing. As a result, on 4/23/2024, at 3 p.m., Resident 1 fell forward from the Sara lift. […]

• Actual harm, isolatedF744Apr 15, 2024

  Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), was assessed at high risk for falls, and elopement (a resident who's incapable of protecting himself/herself adequately and who departed the health care facility unsupervised and undetected) received care and services to prevent a fall by failing to: 1. Implement Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) interventions related to repetitive wandering (moving from place to place without a fixed plan) behavior and attempts to leave the facility unattended. 2. […]

• No harm, potential for more than minimal, widespreadF880Feb 11, 2021

  Based on observation, interview, and record review, the facility failed to provide a safe, sanitary environment to help prevent the spread of infections during the Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) as indicated in the facility's policy and procedure by failing: 1. To ensure that their staff perform hand hygiene before and after contact with a resident 2. To ensure that residents in Green Zone (cohort for residents who completed quarantine, cleared isolation, have no known exposure to COVID- 19 positive individual or have tested negative and remained asymptomatic after last negative testing) area and in Red Zone (The Red Zone is the area where COVID-19 positive patients reside to prevent the spread of the disease) are screened for COVID-… […]

• No harm, potential for more than minimal, patternF578Jan 2, 2026

  Based on interview and record review the facility failed to inform and provide written information regarding advance directives (a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for two of five sampled residents (Residents 21 and 22). This failure resulted in Residents 21 and 22 being uninformed of their health care rights and had the potential to result in conflict regarding Residents' 21 and 22's health care decision choices.Findings: a. […]

• No harm, potential for more than minimal, patternF677Jan 2, 2026

  Based on observation, interview and record review, the facility failed to ensure, three of three sampled residents (Residents 29, 5 and 46), were provided with appropriate activities of daily living (ADLs, basic self-care tasks like bathing, dressing, eating, using the toilet, and moving around).These deficient practices had the potential to result in physical declines due to the lack of assistance with ADLs for Residents 29, 5 and 46.Cross Reference F550Findings: A. During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included glaucoma (eye condition that damages the optic nerve which is crucial for good vision, associated with high pressure in the eye), irritable bowel syndrome (a common… […]