Royal Park Rehabilitation & Health Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, and facility staff, pharmacy staff and Nurse Practitioner (NP) interviews, and record reviews, the facility failed to have effective systems in place for obtaining medications and to ensure they were available to administer to a newly admitted resident in accordance with the physician's orders. This resulted in multiple doses of eleven (11) medications being omitted for 1 of 6 residents (Resident #172) who were reviewed for the availability of their medications.

Inspectors wroteBased on record reviews, observations, and resident and staff interviews, the facility failed to serve food at a palatable temperature, hot foods were served lukewarm or cold and a beverage was served partially frozen for 6 of 6 residents reviewed for food palatability (Resident #8, Resident # 37, Resident #54, Resident #14, Resident #110, and Resident #80). The findings Included:a. Resident 8 was admitted to the facility on [DATE]. Resident #8 had a physician's order dated 2/12/2025 for a cardiac diet with regular texture, a thin consistency, and double portions. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. An observation and interview of Resident #8 was conducted on 12/01/2025 at 2:14 PM during the lunch meal. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to label and date food items and discard expired items in 2 of 3 nourishment rooms (300/400 hall nourishment room and 500/600 hall nourishment room). These deficient practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to store a syringe used for enteral feedings (also known as tube feeding, is a method of delivering nutrition directly into the gastrointestinal tract) dry and with the plunger separated from the syringe and free from moisture for 1 of 3 residents reviewed for enteral feeding management (Resident #73). This practice had the potential for bacterial growth and contamination. Findngs included: Resident #73 was admitted to the facility on [DATE] with diagnoses of diabetes, stroke, hypertension, hemiplegia, malnutrition, difficulty swallowing, esophageal web, gastrostomy status (indicates the presence of a gastrostomy tube, which is surgically placed to provide direct access to the stomach for nutrition and hydration when oral intake is insufficient or unsafe), dysphagia, and oropharyngeal. [...]

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.5% for 3 of 5 residents (Resident #24, Resident #53, and Resident #168) observed during the medication administration observation.

Inspectors wroteBased on observations, record reviews, and resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 3 residents reviewed for food preferences (Resident #136).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge (Resident #163) and Hospice (Resident #7) for 2 of 29 residents reviewed for accuracy of assessments.

Inspectors wroteBased on observations, record reviews and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 out of 1 sampled resident observed with medications left at bedside (Resident #42).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 3 wound care observations on 1 of 2 residents reviewed (Resident #25).

Inspectors wroteBased on record review and interviews with residents, staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 1 resident (Resident #4) reviewed for misappropriation of residents' property.

Inspectors wroteBased 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. The Resident was returned to the facility the same day. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, and test tray the facility failed to provide palatable food that was appetizing in temperature for 2 of 3 residents on the 500 Hall (Resident #1 and Resident #8) reviewed for food palatability. This practice had the potential to affect other residents on the 500 Hall.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 11/19/21, and the recertification and complaint investigation survey that occurred on 03/10/23 This failure was for two deficiencies that were originally cited in the areas of Development and Implementation of Comprehensive Care Plans (F656) and Nutritive Value/Appearance, Palatability/Preferred Temperature of Food (F804) and were subsequently recited on the current complaint investigation survey of 03/25/24. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on observation, record review, staff and Resident interviews, the facility failed to implement care plan interventions by not serving her food to her in large bowls for easier management for 1 of 3 residents reviewed for care plans (Resident #1).

Inspectors wroteBased on observation, record review, staff and Resident interviews the facility failed to serve her food to her in large bowls for easy management for 1 of 3 residents reviewed for choices.

Inspectors wroteBased on record review and staff, resident, Nurse Practitioner, and Physician interviews, the facility failed to ensure a resident was free from a significant medication error when staff failed to administer an oral anti-diabetic medication for 1 of 3 residents reviewed for significant medication errors (Resident #5). This failure resulted in Resident #5 missing a daily dose of an oral anti-diabetic medication for 6 consecutive days.

Inspectors wroteBased on record review and staff, resident interview, Pharmacy Technician, Nurse Practitioner, and Physician interviews, the facility failed to acquire and provide medication to a resident as ordered by the Physician when staff failed reorder and administer an oral anti-diabetic medication for 1 of 3 residents reviewed for pharmaceutical services (Resident #5). This failure resulted in Resident #5 missing a daily dose of an oral anti-diabetic medication for 6 consecutive days.

Inspectors wroteBased on record review, observations, resident interviews, and staff interviews, the facility failed to provide meals that were palatable for 5 of 5 sampled residents (Resident # 58, #26, #55, #109, #110).

Inspectors wroteBased on 2 of 2 observations, staff interviews and record review, the facility failed to remove dried food stains on a wall, clean the doors and drip pans of two convection ovens, remove debris from coils and the vent of the ice machine and a utensil storage rack in the kitchen. This had the potential to affect food served to residents.

Inspectors wroteBase on observations, staff interviews and record reviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions for Range of Motion/ Mobility, Palatable Foods, Food Procurement, Infection Control which were put in place for the recertification and complaint survey dated 11/19/21, Range of Motion/ Mobility which were put in place for the complaint investigation survey dated 1/24/22, and on the current recertification and complaint survey dated 3/6/23. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on observations, record reviews, resident, family, and staff interviews, the facility failed to utilize a left-hand splint as ordered to maintain or improve range of motion/mobility for 1 of 3 residents (Resident #96) reviewed for range of motion.

Inspectors wroteBased on observations and staff interviews, the Patient Advocate and Nurse Aide #3 failed to assist with or provide hand hygiene for residents prior to meal service for 5 of 5 residents (Resident #78, #84, #226, #71 and #121) and perform hand hygiene between residents while distributing meal trays for 1 of 2 staff (Patient Advocate).