Resident 98, who had severe cognitive impairment and required moderate assistance for toileting, died unexpectedly while sitting on the toilet with a laceration above the left eyebrow. The medical examiner requested photographs of the head injury to determine its severity.
Licensed Practical Nurse MM took the pictures with her personal mobile phone and texted them directly to the medical examiner's work phone. She then immediately deleted the photographs from her device, according to a handwritten statement she provided to facility administrators.
The images never made it into Resident 98's medical record, where they belonged under federal documentation requirements.
"The nurse who took the pictures of Resident 98 deleted the picture from their phone after they were sent to the ME," Corporate Licensed Nurse KK told inspectors. She acknowledged the photographs were missing from the resident's medical record.
Multiple staff members confirmed the facility's strict policies against using personal devices to photograph residents. The employee handbook explicitly prohibits direct care staff from using or having cell phones turned on while on duty, allowing personal phone use only during breaks in non-resident care areas.
"Staff were not allowed to photograph residents, especially by using a staff's personal electronic device," Nursing Assistant GG explained to inspectors. Health unit coordinators were designated to take resident profile pictures using facility tablets that automatically uploaded images to the computer system.
Licensed Practical Nurse LL stated that medical photographs "should be in their medical record" and acknowledged that using personal phones to photograph residents "would violate HIPAA."
The facility's admission agreement, which the severely cognitively impaired Resident 98 had electronically signed rather than a legal representative, authorized the center to take photographs for identification and medical purposes. It also promised not to disclose personal health information without written authorization except as permitted by law.
Administrator A confirmed that "Resident 98's picture was taken using a staff's personal cell phone and transmitted to the ME via normal text messaging."
Director of Nursing B acknowledged that "staff should not take resident pictures using their own personal cell phones because of HIPAA concerns" and confirmed that facility mobile devices should be used instead.
The medical examiner verified receiving "two photographs of Resident 98's head injury via text messaging" to determine the injury's severity.
Health unit coordinator NN explained the proper protocol: "Pictures taken with the facility's mobile tablet were automatically uploaded to the facility computer." She confirmed staff were prohibited from using any devices besides facility equipment to photograph residents.
Inspectors also documented widespread infection control failures that put residents at risk of acquiring communicable diseases.
Staff repeatedly ignored transmission-based precautions for Resident 61, who had shingles and was under contact precautions requiring gowns and gloves before entering the room. A contact precaution sign posted outside the room clearly instructed staff to perform hand hygiene and wear protective equipment.
On January 8, Nursing Assistant R entered Resident 61's room "without performing hand hygiene or putting on a gown or gloves." She walked halfway into the room, adjusted the privacy curtain, shut off the call light, and left.
Resident 61's roommate told inspectors that "staff did not clean the toilet after Resident 61 used it" and that "the garbage in the room often overflowed with used and soiled gloves" — garbage the roommate emptied because staff didn't.
"Oh yeah, that rash is driving me nuts," Resident 61 told inspectors, lifting blankets to show the blistery rash on the right groin and inner upper thigh that required contact precautions.
The roommate explained that staff told them they "only had to put a gown and gloves on when they worked with Resident 61 but not when they worked with them."
Housekeeper EE acknowledged that garbage in transmission-based precaution rooms "got full from evening/night shifts and needed emptied in the morning" but said housekeeping typically waited until the end of the day to clean these rooms. She confirmed that "residents in TBP rooms should not empty out the garbage because it was a potential infection control issue."
Some nursing assistants demonstrated basic knowledge gaps. When asked what contact precautions were, Nursing Assistant G "was unable to state" the requirements.
Registered Nurse E confirmed that "staff were to disinfect the toilet between residents and empty garbage in TBP rooms, not the residents, because of potential infection control issues."
Acting Infection Preventionist J explained that contact precautions required staff to "put a gown and gloves on prior to crossing the threshold of the room" and that "trash in TBP rooms should be emptied by staff, not residents."
Director of Nursing B acknowledged that "a gown and gloves should be placed prior to crossing the threshold of a room on contact precautions."
Hand hygiene violations were equally pervasive. Inspectors observed nursing assistants delivering multiple lunch trays without washing hands or using alcohol-based hand rub between resident rooms.
On January 7, Nursing Assistant R delivered lunch trays to three different rooms without performing hand hygiene before or after each delivery. Similar violations occurred on January 15 when the same assistant delivered trays to two rooms without hand hygiene.
Nursing Assistant DD also delivered a lunch tray without performing hand hygiene before or after the delivery.
When confronted, Nursing Assistant R stated that hand hygiene meant "washing their hands but there was no way to do it when passing trays."
Resident Care Manager D corrected this misunderstanding, explaining that hand hygiene "was to be performed when entering or exiting a resident room, before serving meals, between residents, before and after cares."
The facility also failed to offer current COVID-19 vaccines to staff, despite having a resident who tested positive for the virus during the inspection period.
Three nursing assistants reviewed by inspectors had received only initial COVID-19 vaccinations from 2021, with no recent boosters. Staff G received vaccines in May and June 2021 and signed a declination in July 2023, but said they "had never received any education regarding the vaccine and had not been offered one recently."
Staff H "did not remember being offered a COVID-19 vaccine recently unless it was offered as part of their initial employment onboarding paperwork."
Acting Infection Prevention Nurse J confirmed the facility "did not offer COVID-19 vaccines to staff" and instead encouraged them to seek vaccinations from primary care providers or pharmacies. She admitted not keeping track of staff education or vaccination status.
This occurred while the facility was managing a COVID-19 case — a resident who had been at the facility for six days before testing positive after developing respiratory symptoms.
The violations occurred at a 120-bed facility where Resident 98's roommate now empties overflowing garbage bags filled with contaminated gloves because staff won't do it themselves.
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.
Additional Resources
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