Royal Oaks Nursing And Rehabilitation Center

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on clinical record review and staff interviews, the facility failed to complete follow up assessments following a fall for one of four residents (Res #18) reviewed for falls. Findings include:The Progress Note of Resident #18 dated 8/22/25 at 11:44 am, authored by Staff O, Registered Nurse noted IDT (interdisciplinary team) met to discuss fall on 8/21/25. RCA (root cause analysis) performed. Hoyer (full body mechanical lift) sling to be tucked into sides of wheelchair. Review of subsequent progress notes failed to reveal any fall follow up was completed for Resident #18. On 10/21/25 at 3:44 pm, the Director of Nursing (DON) stated no incident report could be located for Resident #18 for a fall on 8/21/25. She agreed there was no documentation in the resident record of staff having followed up with pain assessments, vital signs or neurological checks as is protocol when there is a resident fall. On 10/21/25 at 4:16 pm, Staff O, RN stated she recalled the fall on 8/21/25 was in the morning. 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. She stated the clinical team met and discussed the fall and an appropriate intervention to be put into place. She stated the DON at the time, who is no longer employed at the facility, was to document in the resident chart what had happened. On 10/22/25 at 1:40 pm, the DON stated it appeared the nurse on duty at the time of the fall failed to open up an incident report for the fall. She stated the facility at this time would provide education for documentation and follow up. The Administrator stated the facility had no policy for follow up documentation after a fall.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Royal Oaks Nursing and Rehabilitation Center

4614 NW 84th Street Urbandale, IA 50322

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

F was placed on the Do Not Return list through the staffing agency she is employed through and Staff D did end up being terminated. She acknowledged that Resident #6 did have an allergic reaction, which began prior to Staff F leaving. She stated that Resident #6 had an autoimmune disorder which causes a lot of allergies. She stated when Resident #6 symptoms came on, a nurse didn't get there in time and she self administered her epi pen. She added the medical director wrote new orders that morning, and the facility did a self administration safety assessment. She stated Resident #6 had given herself an epi pen many times (prior to facility admission) and knows how to do it. She added Res #6 keeps an epi pen at her bedside and there is also one in the medication cart. She said they added a special bell in her room that

she rings only in the event of an allergic reaction and also that Res #6 has the DON phone number and can call her at any time. The DON clarified that they had asked Staff D if she had gone down to check on residents on the other side and she stated she had not. She said they asked her why and she stated she was too busy on her side and had too much going on. She said they also asked her if anybody had come and reported anything to her and she stated no, and again said she was too busy. She reported they then asked Staff D if she had called anyone to come help and she replied no because Staff F had told her that

the ADON had been called and nobody came. The DON described that they reiterated to Staff D, did she call anyone and she replied no. The Corrective Action Form of Staff D stated, Staff D was notified by the other nurse in the facility around 2:00 am that she was leaving. This left Staff D as the only nurse in the building until the next shift came in at 6:00 am. Staff D did not call the on-call nurse to have another nurse come to the building. Staff D refused to provide care for any residents that were outside of h[TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Royal Oaks Nursing and Rehabilitation Center

4614 NW 84th Street Urbandale, IA 50322

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on clinical record review, staff interviews and review of facility policy, the facilty failed to maintain complete medical records in accordance with professional standards for three of four residents reviewed (Res #1, #13, #18). Findings include: The Progress Note for Resident #1 dated 2/20/25 identified a witnessed fall and indicated neurological checks were initiated. Additional Progress Notes dated through 2/23/25 referenced continued neurological monitoring.Similarly, an Incident Report for Resident #13 dated 2/19/25 reported a fall. The corresponding Nursing Note dated 2/19/25 at 12:03AM documented neurological checks were initiated at the time of the fall. On 10/20/25 at 10:58 am, the Administrator stated

the facility was unable to produce the neurological check sheets for Res #1 or Res #13. She stated the neuro checks were done on pen and paper and were lost.The Progress Note of Resident #18 dated 8/22/25, authored by Staff O, Registered Nurse noted IDT (interdisciplinary team) met to discuss fall on 8/21/25. RCA (root cause analysis) performed. Hoyer (full body mechanical lift) sling to be tucked into sides of wheelchair. On 10/21/25 at 3:44 pm, the Director of Nursing stated no incident report could be located for Resident #18 for a fall on 8/21/25. She stated she could see one incident report for May and another later in August, neither being related to a fall. On 10/21/25 at 4:16 pm, Staff O, RN stated she recalled the fall on 8/21/25 was in the morning. 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. She stated the clinical team met and discussed the fall and an appropriate intervention to be put into place. She stated the DON at

the time, who is no longer employed at the facility, was to document in the resident chart what had happened. She stated Staff P, LPN was the nurse who was on duty, who quit employment that day. On 10/21/25 at 4:26 pm, Staff P, LPN (former employee) stated the fall happened before she left. She stated

she assessed the resident immediately after the fall to monitor for pain or any injury, and took her vital signs. She stated the resident had no bruising and no sign of injury and following her assessment, two CNAs transferred 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. She stated after her conversation with the DON she went to Human Resources and resigned her position immediately. She stated as she was leaving,

she gave the assessment information of Resident #18 to Staff O, RN and told her she had to leave. On 10/22/25 at 1:40 pm, the DON stated it appeared the nurse on duty at the time of the fall failed to open up

an incident report for the fall. She stated the facility at this time would provide education for documentation and follow up. The facility policy titled Medical Records Organization dated 3/2015 documented a policy statement of:Resident medical records will be organized so that information can be easily retrieved.

Electronic format is acceptable. Resident Record Order documented records that are not electronic may be maintained in paper format. These items included Resident Assessment Forms.

Event ID:

Facility ID:

If continuation sheet