Royal Oaks Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF725Oct 22, 2025

  Based on clinical record review, staff and resident interviews, official city records, facility policy review, and guidance from the Centers for Medicare & Medicaid Services (CMS), the facility failed to provide necessary nursing coverage for approximately four hours on two nursing units housing a total of 53 residents, after one of two on duty nurses left the facility unscheduled. During this period of time, the facility failed to provide requested medications to three residents (Res #3, #6, #9). As a result, one resident's pain (Res #3) became so severe that she contacted 911 (emergency services) to obtain assistance with receiving her pain medication. […]

• Immediate jeopardy, isolatedF755Dec 13, 2024

  Based on observation, clinical record review, staff interview and facility policy review the facility failed to follow professional standards of practice as they allowed the Unit Managers/Supervisors to draw up liquid Morphine (pain medication) and Lorazepam (anti-anxiety medication) in one (1) milliliter (ml) syringes and placed them labeled and unlabeled in the medication carts 3 residents (Res #8, #11 and #13). The staff that drew up the medications failed to dispense the medications and were not licensed pharmacists. The facility also failed to provide sufficient detail to enable an accurate reconciliation and drug records in order to account for all controlled drugs. (Res #2 and #13) The facility identified a census of 83 residents. […]

• Immediate jeopardy, isolatedF684Oct 5, 2022

  Based on record review, policy review and staff interviews the facility failed to accurately assess and provide intervention to 1 of 1 residents who required hospitalization for reasons which included poor perineal hygiene (Resident #1), and for 1 of 3 residents reviewed for substantial weight change (Resident #1). As a result of the failure of the facility to provide accurate assessment and intervention, Resident #1 was hospitalized from 8/19/22-8/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital staff found that Resident #1 was wearing 3 saturated adult briefs, along with associated skin breakdown and swelling of Resident #1's genital area, which resulted in the hospital staff's inability to obtain a urine sample from Resident #1. […]

• Actual harm, isolatedF686Jun 11, 2026

  Based on clinical record review, hospital record review, staff, medical provider and vendor interviews, and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to take steps necessary to avoid the development and worsening of a pressure ulcer for one of four (Resident #8) residents reviewed. This resulted in harm to Resident #8 when her wound continued to worsen and she was sent to the hospital for wound management on [DATE]. Upon admission to the hospital, Resident #8 was diagnosed with a sacral decubitus ulceration extending to the bone. She was additionally diagnosed with an MRSA infection (Methicillin-Resistant Staphylococcus aureus, an antibiotic-resistant infection. […]

• Actual harm, isolatedF690Feb 11, 2026

  Based on observations, clinical record review, consultant pharmacy interview and staff interviews, the facility failed to complete routine urinary catheter care, monitor urinary output and administer an antibiotic to treat an urinary tract infection (UTI) per physician order for 2 of 3 residents (Resident #1 and Resident #11) reviewed for urinary catheter. Resident #1 did not receive a full nine-day course of antibiotics to treat an UTI which resulted in a hospitalization. The facility reported a census of 88 residents Findings include: 1.The Quarterly Minimum Data Set (MDS) Assessment completed on 11/19/25 revealed Resident #11 with a Brief Interview for Mental Status (BIMS) score of 10, indicating a moderate cognitive impairment. […]