Royal Oaks Nursing and Rehabilitation Center failed to maintain complete medical records for three residents, including neurological monitoring sheets that administrators admitted were "done on pen and paper and were lost," according to an October inspection report.
The problems began with Resident #1, who suffered a witnessed fall on February 20. Progress notes documented that neurological checks were initiated and continued through February 23. But when inspectors asked to see the neurological check sheets on October 20, Administrator couldn't produce them.
"She stated the neuro checks were done on pen and paper and were lost," inspectors wrote.
The same pattern emerged with Resident #13. An incident report documented a fall on February 19, and nursing notes from 12:03 AM that day showed neurological checks were started immediately. Those records, too, had vanished.
The most complex case involved Resident #18, whose August 21 fall triggered a chain of events that left a gap in medical documentation. A progress note dated August 22 showed the interdisciplinary team had met to discuss the fall and performed a root cause analysis. The team decided the resident's Hoyer lift sling should be tucked into the sides of their wheelchair to prevent future incidents.
But no incident report existed for that fall.
Staff O, a registered nurse who authored the August 22 progress note, told inspectors she remembered the morning clearly. The nurse covering Station 2, where Resident #18 lived, had quit her job later that same morning after the fall occurred.
"She stated the nurse that was on duty that morning for Station 2, where Resident #18 resides, had walked out on the job later in the morning, after the fall," the inspection report stated.
That nurse was Staff P, a licensed practical nurse who confirmed to inspectors that she had assessed the resident immediately after the fall, checking for pain, injury, and vital signs. She found no bruising or signs of injury, and two certified nursing assistants helped transfer the resident off the floor.
"She stated she had an incident with the DON at the time and stated she was over stimulated and chose to quit employment," Staff P told inspectors. After her confrontation with the director of nursing, she went straight to human resources and resigned.
As she was leaving, Staff P said she gave her assessment information about Resident #18 to Staff O and told her she had to go.
The clinical team did meet to discuss the fall and determine appropriate interventions, as documented in the progress note. But the director of nursing at the time, who no longer works at the facility, was supposed to document what happened in the resident's chart.
That documentation never materialized.
Director of Nursing told inspectors on October 21 that she could find only two incident reports for Resident #18 from that time period — one from May and another from later in August, neither related to a fall.
The current director of nursing, reviewing the case on October 22, concluded that "the nurse on duty at the time of the fall failed to open up an incident report for the fall."
Royal Oaks' own policy, dated March 2015, requires that "resident medical records will be organized so that information can be easily retrieved." The policy specifically states that resident assessment forms may be maintained in paper format when not kept electronically.
The facility told inspectors it would provide education for documentation and follow up.
But for the three residents whose medical records were incomplete or missing entirely, the documentation gaps represent a more fundamental problem. Neurological checks after falls are critical for detecting brain injuries that might not be immediately apparent. Incident reports create the paper trail necessary for identifying patterns and preventing future accidents.
Staff P's abrupt departure on August 21 left Resident #18's fall undocumented in the facility's incident reporting system, despite the fact that the clinical team met, analyzed what went wrong, and implemented new safety measures. The interdisciplinary team's work was recorded, but the initial incident that prompted their meeting was not.
For Residents #1 and #13, the neurological monitoring happened but the records documenting that crucial post-fall care simply disappeared. Federal inspectors found that three of the four residents whose records they reviewed had incomplete medical documentation.
The facility's administrator acknowledged the lost paperwork but offered no explanation for how neurological check sheets for two separate residents, documented over multiple days in February, could both vanish from the medical record system.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Oaks Nursing and Rehabilitation Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
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