Royal Park Rehabilitation & Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 25, 2024

  Based on observation, record review and Resident, transportation company staff, insurance manager, facility staff, Wound Physician and Medical Director interviews, the facility failed to secure Resident #1 and her wheelchair to the vehicle according to the manufacturer's instructions to prevent her from sliding forward from the wheelchair during a contracted van transport. When the driver applied the brakes in traffic it caused Resident #1 to slide forward from the wheelchair, her face on the back of the driver's seat and pinning her right kneecap on the van floor. Resident #1 was taken to the hospital for evaluation and a computed tomography (CT) scan of her head and spine resulted negative and three x-ray views of the right knee resulted negative. […]

• Actual harm, patternF679Mar 25, 2024

  Based on record review, activity calendar and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 6 of 7 residents reviewed for activities (Residents #1, #2, #3, #4, #5 and #6). The residents expressed not being able to leave the facility for over a year made them feel like they had lost some of their independence, felt terrible, isolated, confined, sad, trapped, and they missed getting out and socializing with a group and seeing people outside the facility. […]

• Actual harm, isolatedF690Dec 5, 2025

  Based on record review and Medical Director, Hospital Urologist, Nurse Practitioner (NP), Resident Representative (RR) and staff interviews, the facility failed to follow hospital discharge orders for a urinary catheter to remain in place for 1 of 5 residents reviewed for urinary catheters (Resident #161). Resident #161 was admitted to the facility from the hospital on 9/18/25 with a urinary catheter due to a diagnosis of hydronephrosis (swelling of the kidneys due to urinary retention). Resident #161's urinary catheter was removed at the facility on 9/19/25 at 6:27 AM and subsequently reinserted at 11:09 PM after the Medical Director reviewed the hospital records which indicated the urinary catheter was to remain in place until follow up with urology. […]

• Actual harm, isolatedF687Mar 25, 2024

  Based on observations, record review, resident and staff interviews, the facility failed to provide podiatry services and/or toenail care for 2 of 2 sampled residents (Resident #3 and Resident #1) reviewed for foot care. Resident #3 reported difficulty getting his socks on every morning and having to walk differently due to the condition of his toenails and reported the big toenails on both feet were ingrown. The findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes mellitus type II with complications. Resident #3's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was independent with personal hygiene. […]

• No harm, potential for more than minimal, widespreadF880Nov 19, 2021

  Based on observations, record review, staff interviews, facility policy review and the Centers for Disease Control (CDC) COVID-19 Tracker for [NAME] county transmission rate, the facility failed to immediately implement Transmission Based Precautions (TBP) for 2 of 2 COVID-19 positive residents (Resident #86 and Resident #31), failed to implement COVID-19 screening policy when 2 of 2 employees reported symptoms of COVID-19 (Receptionist #1 - chills, muscle and body aches, headache and sore throat, Nurse #1 - cough, muscle and body aches) were allowed to work and then tested positive for Covid -19 during their shift, failed to follow CDC guidance regarding appropriate Personal Protective Equipment (PPE) for counties of substantial to high county transmission rates when 3 of 3 staff members… […]