Royal Park Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Royal Park Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF691Jul 16, 2025

  Based on interview and record review, the facility failed to ensure provider orders were consistently followed to track ostomy (a surgically placed opening [stoma] in the abdomen to allow body waste to pass into a collection bag) output, teach the resident to manage their ostomy independently, consistently assess and monitor skin around the stoma and provide and document ostomy care consistent with professional standards for 1 of 1 resident (Resident 1) reviewed for ostomy care. Resident 1 experienced harm when they developed excoriation (skin breakdown), redness and weeping, around their ostomy so facility staff were unable to securely adhere the ostomy bag to the skin and required the resident's transfer to the hospital for evaluation and treatment. […]

• Actual harm, isolatedF689Apr 14, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate staff supervision for the bed mobility and reassess a resident's ability to assist after a room change and level of consciosness to prevent accidents for 1 of 3 sampled residents (Resident 2), reviewed for falls. Resident 2 experienced harm when they were rolled toward the edge of their bed by a staff member during a bed linen change, rolled off the bed headfirst onto the floor, required transfer to the hospital and sustained a subdural hematoma (a serious condition where blood collects between the skull and the surface of the brain, usually caused by a head injury). Findings included . […]

• Actual harm, isolatedF697Apr 14, 2025

  Based on interview and record review, the facility failed to administer the correct dose of pain medication for 1 of 3 sampled residents (Resident 1), reviewed for medication errors. Resident 1 experienced experienced harm when they had uncontrolled pain that required hospital transfer when Staff administered 50 mg of Tramadol (an opioid medication used for moderate to severe pain) instead of 100 mg, as ordered. Findings included . Review of a facility assessment, dated 03/17/2025, showed Resident 1 was admitted with diagnoses to include sciatica (a condition where a nerve root in the lower back was compressed or irritated which could cause pain and radiated down the leg along the affected nerve) and a progressive neurological disorder that affected movement. […]

• Actual harm, isolatedF684Nov 13, 2024

  Based on interview and record review, the facility failed to provide the necessary care and services to maintain the resident's highest practicable level of well-being for 1 of 3 residents (Resident 1) reviewed for diabetes management. Resident 1 experienced harm when they were found unresponsive from a blood sugar of 39 milligrams (mg)/deciliter (dl) (a normal blood sugar ranges from 80 mg/dl to 130 mg/dl) and Staff administered an oral glucose gel which resulted in Resident 1 aspiration (when food or drink goes into the lung). This failure placed other residents at risk for diminished quality of care. Findings included . Review of the facility assessment, dated 10/28/2024, showed Resident 1 had diagnoses to include diabetes and lung disease. […]

• Actual harm, isolatedF600Aug 2, 2024

  Based on observations, interview, and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 3 sampled residents (Resident 1), reviewed for abuse. Resident 1 experienced harm when they reported a staff member had sexual intercourse with them and the sexual assault exam showed abrasions consistent with penile penetration. This failure placed the resident at risk for further abuse and psychosocial harm. Findings included . Review of the facility's policy titled Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy, updated 10/2022, showed each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse . […]