Federal inspectors documented the breathing equipment failures and chronic understaffing during a January 17 inspection, finding that basic care plans were ignored even for residents at highest risk.
Resident 81, who suffered cognitive impairment and paralysis from a previous stroke, required a BIPAP machine whenever sleeping to prevent breathing interruptions that could trigger another stroke. The resident's spouse told inspectors it was critical for preventing "high risk for another stroke and decreased alertness from not sleeping well."
Inspectors found the resident sleeping without the machine six separate times over four days in January. On January 14 at 8:34 AM, when the resident woke up during an inspection observation, they told inspectors "they didn't get much sleep yesterday."
The facility's care plan, developed December 10, specifically instructed licensed staff to "ensure the BIPAP was worn by the resident while sleeping, including naps as ordered." Nursing assistant Staff DD told inspectors the resident used BIPAP "at night" but incorrectly stated they "did not use it during the day when they napped."
Director of Nursing Staff B confirmed to inspectors that the resident needed the breathing machine "whenever sleeping, including naps as ordered."
The breathing equipment failures occurred amid what residents described as a staffing crisis that left basic needs unmet for hours.
Resident 31, who relies on oxygen therapy for chronic respiratory failure and pulmonary embolism, told inspectors they removed their oxygen to use the bathroom because staff wouldn't respond to call lights. After waiting 35 minutes without response last week, the resident "began to yell out because they needed their oxygen."
The resident explained they "should not be taking themselves to the bathroom but did because staff would not respond to their call light timely." They kept their room door open "in case of emergencies, because staff did not respond to call lights timely."
Resident 27, who is legally blind and requires mechanical lift transfers, fell four times between November and December after attempting to transfer independently while waiting for help. Care plans specifically instructed staff "not to leave Resident 27 unattended on the toilet" and to "anticipate Resident 27's needs."
On November 17, the resident was found sitting on the bathroom floor after being "left on the toilet unattended." On December 5, they were discovered "lying on the bathroom floor holding the back of their bleeding head" after attempting to transfer onto the toilet independently.
During the inspection, a visitor watching the resident's call light complained to passing staff: "Where is an aide at? [Resident 27] needs to go to the bathroom, last time [Resident 27] fell, [staff] better get down here, we will see how long this takes." The call light remained on for several minutes before staff responded.
The resident's friend told inspectors that increased diuretic medication caused more frequent urination, but "Resident 27 attempted to self-transfer because they waited too long for staff to answer their call light."
Facility grievance logs revealed the scope of the staffing problems. Between July and December 2024, residents filed multiple complaints about ignored call lights and inadequate response times.
Resident 40 filed grievances in August, September, and December about staff "ignoring call lights and played on their mobile phones" and using the Oak activity room as a break room "while residents had call lights on in the halls." The resident told inspectors they still received medications around 3:30 AM and would "often come out in search of the nurse to find staff using the Oak activity room as a breakroom."
Resident 31 waited 45 minutes for help with personal hygiene after incontinence in November. Resident 24 waited an hour and a half for staff assistance, also in November.
Resident 28 told inspectors they approached the nurses' station after waiting 50 minutes for their call light and "observed staff sitting around while call lights were going off."
Nursing assistant Staff G acknowledged that "residents had excessively long call light wait times when not enough staff." Registered Nurse Staff E confirmed "residents had to wait a long time to get help when there was not enough staff."
The facility's staffing coordinator provided inspectors with a handwritten staffing guide that assigned between three and eight direct care staff to Oak hall, the long-term care unit. Staff acknowledged that rooms 128 through 146 housed "heavier care needs with higher use of full body lifts for dependent residents."
Resident Care Manager Staff D admitted that section assignments based on resident needs weren't followed: "floor staff did not honor managements changes and readjust the assignments." The manager acknowledged "some residents had excessively long call light wait times, especially the back of Oak hall, rooms 128 through 146."
An anonymous staff member told inspectors the back section "was too much for one person to handle" and that finding help for required two-person mechanical lift transfers sometimes took 20 minutes. The staff member said they had "informed management, but nothing had been done yet."
When staff called in sick, the facility pulled workers from other programs, including shower aides and restorative therapy staff. Staff D explained that when restorative aides were moved to floor care, "no staff replaced restorative because they did not have the training, there was no restorative program."
The facility acknowledged having no tracking system for documenting attempts to fill staffing gaps when workers called in sick.
Administrator Staff A claimed section assignments were "readjusted based on resident acuity nightly," contradicting staff accounts that management changes weren't implemented on the floor.
The inspection found that five residents experienced care failures directly related to insufficient staffing, placing all 105 residents at the facility at risk for accidents, unmet care needs, and diminished quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Park Health and Rehabilitation from 2025-01-17 including all violations, facility responses, and corrective action plans.
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