Royal Oak Nursing Center
37300 Royal Oak Lane, Dade City, FL 33525 · Pasco County · (352) 567-3122
120 certified beds, about 108 residents a day · Non profit - Corporation · Medicare and Medicaid since 1981
Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
4 of 5
Health inspections
3 of 5
Staffing
4 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 105385 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 28, 2024, inspectors cited 6 health deficiencies (the Florida average is 7.1, the national average 9.2).
None of its 14 health citations since October 2020 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.75 hours per resident per day, against 3.82 across Florida and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.
41.2% of nursing staff left within the year CMS measured (Florida average 41.4%).
CMS links it to Health Services Management, an affiliated group of 16 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
110/20
601/22
603/24
102/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
4E
0F
Potential for minimal harm
0A
0B
0C
February 2, 2026Complaint inspection · 1 citation
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure isolation protocols were followed related to PPE (personal protection equipment) use and notifying visitors of infections, in two rooms (231 and 230) out of 15 rooms in hall 200.
March 28, 2024Standard inspection · 6 citations
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment and documentation for discovered skin discolorations / bruising was performed for three (Residents #201, #6, and #19) of 22 sampled residents and failed to ensure wound dressings were dated and initialed for one (Resident #252) of 22 sampled residents.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices and procedures were followed during medication administration for four (Residents #260, #259, #13 and #35) of seven sampled residents and one (Resident #84) of one sampled resident related to proper storing of a nebulizer mask.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, interview, and review of the facility's policy Self-Administration of Medications the facility failed to ensure two (Residents #84 and #262) out of 22 sampled residents were clinically appropriate to self-administer medications.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review, interview, and review of the facility's policy Care Plans, Comprehensive Person-Centered the facility failed to develop a patient-centered care plan for one (Resident #84) out of twenty-two sampled residents related respiratory care and services.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that activities of daily living related to nail care were provided for one (Resident #9), out of five sampled residents.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, record review, and interview, the facility failed to identify and educate staff of specific behaviors and triggers related to Post Traumatic Stress Disorder (PTSD) for one (Resident #77) of two sampled residents who had PTSD.
January 14, 2022Standard inspection · 6 citations
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure assistance with Activities of Daily Living (ADL) for dependent residents was provided for six (Resident #17, #26, #27, #21, and #78) of 33 sampled residents.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than 5%. A total of 34 administration opportunities were observed with 16 medication errors for three (Resident #70, Resident #72, and Resident #240) of six residents observed for medication administration, resulting in a medication administration error rate of 47.06%.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure wanderguard functioning and placement was properly and consistently documented for one (Resident #239) of two residents sampled for wanderguards.
- D Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and review of the employee orientation and training handbook, the facility failed to ensure one of four nurses working on 1/13/22 from the 3:00 p.m. to 11:00 p.m. shift was trained and competent using the electronic medical record to ensure resident safety regarding medication and treatment administration. Findings Included: During an interview with Staff J, RN agency nurse on 1/13/22 at 4:55 p.m., she confirmed today was her first day working in the building. Staff J confirmed she was not trained on the facility computer system and never had an in-service to find, document, and ensure medications and treatments were completed as ordered. Staff J confirmed Resident #26 was in need of wound care that was not completed during the day. She said she was unable to access the computer system to find where and what type of wound care to provide. [...]
- D 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.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure proper monitoring of psychotropic medication was implemented for one (Resident #239) of six residents sampled for Unnecessary Medications.
- D Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #84) of 25 resident beds was inspected to ensure the frame and mattress were compatible with the resident's height to ensure safety from his feet hanging over the end of the bed. Findings Included: Observation on 1/11/22 at 10:00 a.m., revealed Resident #84 sitting up in bed with his feet to his heels hanging off the end of the bed. The resident stated he was 6 foot 2 inches and his heels always hung off the end of the bed. The bed was observed without a foot board, bed extender, or side rails. Observation on 1/13/22 at 8:54 a.m. revealed Resident #84 sitting up in bed with his feet hanging over the end of the bed. The resident stated he never had a footboard that he could remember or extender on his mattress. [...]
October 15, 2020Standard inspection · 1 citation
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, record review, and interviews the facility did not ensure that controlled substances schedule II-V were stored in permanently affixed compartments in one of two medication rooms sampled during the performance of the facility task of Medication Storage and Labeling.
Fire safety inspections
12 fire safety citations on file: 2 on March 28, 2024, 1 on January 14, 2022, 9 on October 15, 2020.
Every fire safety citation12 citations
- D Inspect, test, and maintain automatic sprinkler systems.
- D Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D Install an approved automatic sprinkler system.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Have properly located and lighted "Exit" signs.
- D Have properly installed hallway dispensers for alcohol-based hand rub.
- D Have approved installation, maintenance and testing program for fire alarm systems.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Ensure proper usage of power strips and extension cords.
- D Ensure that testing and maintenance of electrical equipment is performed.
- D Have proper medical gas storage and administration areas.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Florida | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.75 | 3.82 | 3.86 |
| Registered nurses | 0.70 | 0.73 | 0.69 |
| All nursing staff on weekends | 3.32 | 3.49 | 3.42 |
| Nurse aides | 2.37 | ||
| Licensed practical nurses | 0.69 | ||
| Nursing staff turnover (share who left in a year) | 41.2% | 41.4% | 45.8% |
| Registered nurse turnover | 35.0% | 46.0% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.54 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.93 on weekdays and 3.32 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.63 in April to June 2025 to 3.75 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.75 | 0.70 | 3.93 | 3.32 | 1.8% | 0 of 90 | 108 |
| Oct to Dec 2025 | 3.68 | 0.71 | 3.86 | 3.21 | 1.3% | 0 of 92 | 106 |
| Jul to Sep 2025 | 3.69 | 0.72 | 3.86 | 3.25 | 1.9% | 0 of 92 | 104 |
| Apr to Jun 2025 | 3.63 | 0.68 | 3.80 | 3.20 | 3.0% | 0 of 91 | 109 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Florida, Jan to Mar 2026 | 3.76 | 0.70 | 3.90 | 3.44 | 1.1% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Florida | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.5 | 8.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.0 | 0.7 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.3 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.4 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 29.9 | 9.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.4 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 4.6 | 8.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 13.0 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 5.9 | 9.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.1 | 1.8 |
Owners and operators
Legal business name: ROYAL OAK NURSING CENTER, LLC. CMS links this home to Health Services Management, a group of 16 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Health Services Management, Inc. | 5% or greater direct ownership interest | Organization | 100% | 10/01/2000 |
| National Health Investors, Inc. | 5% or greater mortgage interest | Organization | 11/01/1990 | |
| Nhi-Reit of Florida, LLC | 5% or greater mortgage interest | Organization | 11/01/1990 | |
| Baxter, Kevin | Corporate officer | Individual | 11/01/1990 | |
| Fisher, Scott | Corporate officer | Individual | 04/02/2012 | |
| Jackson, Brian | Corporate officer | Individual | 11/01/1990 | |
| Shatz, Jim | Corporate officer | Individual | 04/06/2021 | |
| White, Joshua | Corporate officer | Individual | 11/01/1990 | |
| Health Services Management, Inc. | Operational/managerial control | Organization | 10/01/2000 | |
| Fisher, Scott | Operational/managerial control | Individual | 11/01/1990 | |
| Gant, Amy | Operational/managerial control | Individual | 08/17/2015 | |
| Hashmi, Haseeb | Operational/managerial control | Individual | 03/01/2024 | |
| Jackson, Brian | Operational/managerial control | Individual | 11/01/1990 | |
| Shatz, Jim | Operational/managerial control | Individual | 11/01/1990 | |
| White, Joshua | Operational/managerial control | Individual | 11/01/1990 | |
| National Health Investors, Inc. | Adp of the SNF | Organization | 11/01/1990 | |
| Nhi-Reit of Florida, LLC | Adp of the SNF | Organization | 11/01/1990 | |
| Gant, Amy | Adp of the SNF | Individual | 08/17/2015 | |
| Hashmi, Haseeb | Adp of the SNF | Individual | 03/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 5 problems in this area, most recently on March 28, 2024: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on January 14, 2022: "Ensure medication error rates are not 5 percent or greater."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on February 2, 2026: "Provide and implement an infection prevention and control program."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on March 28, 2024: "Allow residents to self-administer drugs if determined clinically appropriate."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.32 hours per resident per day, below the Florida average of 3.49.
Other nursing homes nearby
- Dade City Health and Rehabilitation Center Dade City, 0.4 mi · 1 of 5 stars · 54 citations
- Solaris Healthcare Zephyrhills Zephyrhills, 6.1 mi · 5 of 5 stars · 18 citations
- Hillside Health and Rehabilitation Center Zephyrhills, 7.2 mi · 3 of 5 stars · 31 citations
- Solaris Healthcare Lake Zephyr Zephyrhills, 8.6 mi · 3 of 5 stars · 16 citations
- Blue Heron Health and Rehabilitation Wesley Chapel, 13.1 mi · 4 of 5 stars · 18 citations
- Baldomero Lopez Memorial Veterans Nursing Home Land O Lakes, 16.5 mi · 5 of 5 stars · 8 citations
- Northbrook Center for Rehabilitation and Healing Brooksville, 18.2 mi · 2 of 5 stars · 23 citations
- Brooksville Healthcare Center Brooksville, 18.2 mi · 3 of 5 stars · 21 citations
Florida contacts for a concern about a nursing home
These are the official offices in Florida. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Florida Agency for Health Care Administration, Long Term Care Services Unit, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Florida Long-Term Care Ombudsman Program, 1-888-831-0404. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: FloridaHealthFinder, where Florida publishes its own records on licensed homes.
Common questions
- What is Royal Oak Nursing Center's Medicare star rating?
- CMS rates Royal Oak Nursing Center 4 out of 5 stars overall, with 3 for health inspections, 4 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Royal Oak Nursing Center get at its last inspection?
- 6 health deficiencies at the standard inspection on March 28, 2024. The Florida average is 7.1.
- Has Royal Oak Nursing Center been fined?
- CMS lists no fines in the last three years.
- Does Royal Oak Nursing Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Royal Oak Nursing Center?
- CMS lists 19 owners and managers, and links the home to Health Services Management. Legal business name: ROYAL OAK NURSING CENTER, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.