Royal Oaks Nursing and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF660Sep 22, 2022

  Based on interview and record review, the facility failed to revise discharge plan to reflect additional care needs related to a change in status, and failed to involve the resident's representative, appropriate staff, and the Home Health Agency in education and decision-making to ensure safety, continuity of care and prevent hospital readmission for 1 of 5 residents reviewed for discharge planning, of a total sample of 8 residents, (#1). The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/08/22, the day of her planned discharge home, resident #1 fell in her room and hit the back of her head. […]

• Immediate jeopardy, isolatedF684Sep 22, 2022

  Based on interview and record review, the facility failed to provide and/or arrange post-fall care and services in accordance with facility protocols and professional standards of practice; and failed to adequately inform and educate the resident and her representative regarding the symptoms and risks of a closed head injury to prevent a negative outcome and promote the highest practicable well-being for 1 of 4 residents reviewed for falls, of a total sample of 8 residents, (#1). The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident experienced ongoing residual effects of the brain bleed including memory and language deficits. On 6/08/22, the day of her planned discharge home, resident #1 fell in her room and hit the back of her head. […]

• No harm, potential for more than minimal, patternF584Feb 25, 2026

  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. […]

• No harm, potential for more than minimal, patternF812Jun 26, 2024

  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. […]

• No harm, potential for more than minimal, patternF550Dec 15, 2022

  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. […]