A list of the most recent deficiencies for Royal Oaks Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-02-14 | 2024-03-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-14 | 2024-03-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-14 | 2024-03-09 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-02-14 | 2024-03-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-14 | 2024-03-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-14 | 2024-03-09 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-02-14 | 2024-03-09 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-14 | 2024-03-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-26 | 2023-12-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-26 | 2023-12-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-26 | 2023-12-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-26 | 2023-12-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-10-26 | 2023-12-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-26 | 2023-12-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-26 | 2023-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-12-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-26 | 2023-12-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-26 | 2023-12-13 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-26 | 2023-12-13 | N |
| Post nurse staffing information every day. | Health | 2023-10-26 | 2023-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-26 | 2023-12-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-26 | 2023-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-26 | 2023-12-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-26 | 2023-12-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-26 | 2023-12-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-26 | 2023-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-01 | 2023-11-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-01 | 2023-11-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-01 | 2023-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-01 | 2023-11-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-01 | 2023-11-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-01 | 2023-11-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-01 | 2023-11-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-13 | 2023-09-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-13 | 2023-09-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-13 | 2023-09-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-24 | 2023-07-07 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-24 | 2023-07-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-20 | 2023-03-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-08 | 2023-03-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-08 | 2023-02-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-08 | 2023-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-08 | 2023-02-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-16 | 2022-12-22 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-29 | 2022-10-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-29 | 2022-10-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-09-29 | 2022-10-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-29 | 2022-10-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-29 | 2022-10-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-29 | 2022-10-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-29 | 2022-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-10-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-29 | 2022-10-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-29 | 2022-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-10-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-10 | 2022-09-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-10 | 2022-09-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-24 | 2022-09-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-27 | 2022-05-13 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-21 | 2022-01-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-27 | 2021-09-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-08-27 | 2021-09-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-27 | 2021-09-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-09-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-27 | 2021-09-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-27 | 2021-09-15 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-08-27 | 2021-09-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-27 | 2021-09-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-27 | 2021-09-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-27 | 2021-09-15 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-15 | 2021-07-27 | Y |
