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Inspection visit

Inspection

Royal Oaks Nursing and Rehabilitation CenterCMS #16558024 citations on this visit
24 citations recorded

Citations

24 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0842GeneralS&S Epotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0004GeneralS&S Fpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0030GeneralS&S Fpotential for harm

    List the names and contact information of those in the facility.

  • 0281GeneralS&S Dpotential for harm

    Install proper backup exit lighting.

  • 0321GeneralS&S Dpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0920GeneralS&S Epotential for harm

    F920 - Dining and Resident Activities

    Ensure proper usage of power strips and extension cords.

  • 0922GeneralS&S Dpotential for harm

    F922 - Establish procedures to ensure that water is available to essential areas

    Meet requirements for the use and maintenance of medical gas equipment.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0689SeriousS&S Gactual harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0740GeneralS&S Dpotential for harm

    F740 - Behavioral health services

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  • 0760SeriousS&S Gactual harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0372GeneralS&S Epotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0511GeneralS&S Epotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0521GeneralS&S Fpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

FAQ · About this visit

Common questions about this visit

What happened during the May 20, 2025 survey of Royal Oaks Nursing and Rehabilitation Center?

This was a inspection survey of Royal Oaks Nursing and Rehabilitation Center on May 20, 2025. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Royal Oaks Nursing and Rehabilitation Center on May 20, 2025?

Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.