Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Oaks Nursing And Rehab Center during CMS and state inspections, most recent first.
Homelike Dining Environment Not Maintained: Staff served residents’ meals on trays in the west wing dining area and left plates, cups, bowls, and utensils on the trays instead of removing them and placing them on the table. This was observed with multiple residents during meal service, and a family member removed items from one resident’s tray while staff continued serving meals without making the same change. The Administrator later agreed the items should have been removed and stated the expectation was to provide a home-like environment in each dining area.
Failure to Assess Self-Administration of Medications: Surveyors found ophthalmic and nasal medications at the bedside of three cognitively intact residents, and each said they were using the medications on their own. The LPN confirmed there were no orders or self-administration assessments in place for the medications, including eye drops and nasal sprays, despite residents having diagnoses such as glaucoma, dry eye, COPD, and other chronic conditions.
A resident with an IV midline for wound infection had orders to discontinue and remove the line after antibiotics were completed, but the line remained in place and was not documented as removed. Another resident with CVA-related right-sided weakness had an order for a resting hand splint to the right wrist/hand, but staff did not consistently apply it, the order was not on the TAR or CNA task list, and there was no refusal documentation when the resident was observed without it.
A resident with a bladder catheter was observed with the drainage bag on the floor while seated in a chair, and later the bag was again seen on the floor. Staff, including the UM nurse, LPNs, CNA, and DON, stated the bag should be hung below bladder level and not left on the floor; the facility policy also stated not to rest the catheter bag on the floor.
During a kitchen inspection, the deep fryer was found unclean with food debris and dark cooking oil, indicating neglect in maintenance. The cook confirmed the fryer had not been used that morning and was unsure of the last cleaning or oil change, highlighting a lack of regular cleaning schedule adherence.
A resident with heart disease, renal disease, and hyponatremia was on a physician-ordered fluid restriction of 1000 ml per day. However, the resident was observed with a large cup of water exceeding the daily allowance, and neither the resident nor the CNA was aware of the restriction. The CNA confirmed the restriction upon reviewing the electronic medical record, but the Kardex lacked specific fluid amounts. The Unit Manager acknowledged the oversight, indicating a failure in communication and adherence to the fluid restriction.
Homelike Dining Environment Not Maintained
Penalty
Summary
The facility failed to provide a homelike environment for residents who ate meals in the west wing dining area by serving lunch on trays in an institutional manner and leaving the plates, cups, bowls, and utensils on the trays at the tables. During observation on 2/22/26, five residents were seated in the dining area with their lunch meals on serving trays in front of them, and the items remained on the trays rather than being removed and placed on the table. On 2/23/26, seven residents were observed in the west wing dining areas receiving meals on serving trays, with staff placing the trays on the tables but not removing the items from the trays. A family member removed the items from one resident’s tray and placed them on the table, while staff continued meal service without removing items from any trays. On 2/24/26, four residents were observed in the dining area and three staff members served lunch on trays without removing the items. When the Administrator observed the dining area later that day, he agreed the items should have been removed from the trays and stated it was his expectation that staff provide a home-like environment for residents eating in each dining area. The facility was unable to provide a policy regarding homelike environment in facility dining areas.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to conduct medication self-administration assessments for 3 of 5 residents reviewed for choices, involving residents #31, #55, and #75. Surveyors found ophthalmic and nasal medications at the bedside of these residents, and each resident stated they were using the medications on their own. In each case, staff acknowledged that there were no orders or assessments authorizing self-administration of the medications. Resident #31 had diagnoses including COPD, dementia, CHF, and CKD. Her MDS quarterly assessment showed a BIMS score of 14 out of 15, indicating she was cognitively intact, and her vision was adequate with corrective lenses. She was observed in bed, alert and oriented, with three boxes of artificial tears on her bedside table, and she stated she applied them herself twice a day. The assigned LPN removed the bottles and confirmed there were no self-administration orders or assessment for the resident. Resident #55 had diagnoses including type 2 diabetes, asthma, primary open angle glaucoma, and dry eye syndrome. Her MDS showed a BIMS score of 15 out of 15 and impaired vision with corrective lenses, and her care plan noted impaired vision related to glaucoma and blindness in the left eye. She was observed with cyclosporine eye drops and fluticasone nasal spray at the bedside and stated she used them herself. Resident #75 had diagnoses including parkinsonism, chronic pain, Bell's palsy, bilateral cataracts, and major depressive disorder, and her MDS showed a BIMS score of 15 out of 15 with adequate vision and corrective lenses. She was observed with normal saline nasal spray at the bedside, stated she used it when congested, and the LPN confirmed there were no physician orders or self-administration assessment for her medication use.
Failure to Follow Physician Orders for IV Removal and Hand Splint Use
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with physician orders for a resident with a midline intravenous catheter and for a resident with a resting hand splint. For the resident with the midline, the record showed treatment for an ESBL Proteus mirabilis wound infection with IV Meropenem, followed by orders to discontinue and remove the IV line after antibiotic therapy was completed. However, the midline remained in place, and the electronic treatment record had no documentation for the relevant dates. A weekend supervisor acknowledged attempting to remove the midline but leaving it in place because the resident was in therapy, and the Director of Nursing stated that being in therapy was not an excuse for not removing it and that the physician order should have been followed. For the resident with cerebral infarction, aphasia, dementia, and right-sided upper extremity impairment, the physician ordered a resting hand splint to the right wrist/hand to the resident's tolerance to promote skin and joint integrity. The care plan also included use of the splint. During observation, the resident was seen without the splint on the right hand, and family members stated they rarely saw her wearing it and had asked about it without receiving a response. The Rehab Director confirmed the order, stated nursing was responsible for applying the splint when the resident was no longer on therapy services, and could not explain why the order was not on the MAR or TAR. Staff interviews showed the splint order was only found on the Kardex used by CNAs and was not on the TAR or in the CNA task list in Point of Care. The Unit Manager stated the order may have been entered incorrectly because it did not specify a time of day or duration, and he confirmed there was no documentation of refusal when the resident did not wear the splint. The DON stated the expectation was that physician orders be followed and that the splint order should have been on the TAR so nurses could document whether it was applied or not.
Catheter Drainage Bag Left on Floor
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to supervise a urinary catheter drainage bag in accordance with infection control standards for 1 resident reviewed with a bladder catheter. Resident #14 was admitted with congestive heart failure, atrial fibrillation, urinary retention, peripheral vascular disease, right femoral embolism, and chronic kidney disease. The Quarterly MDS indicated the resident was cognitively intact, used a walker with minimal supervision, and needed moderate assistance with activities of daily living. The care plan included a goal of decreasing the risk of UTI signs and symptoms and other catheter-related complications, with an intervention to position or secure tubing to prevent traumatic removal. On observation, the resident was asleep in a chair and the catheter drainage bag was on the ground, and later the urine collection bag was again observed on the floor while the resident sat in the chair. The Unit Manager Nurse, an LPN, CNA, another LPN, and the DON all stated the bag should be hung below bladder level and not left on the floor; one staff member attached it to the wheelchair after picking it up with gloves. The facility policy for catheter care and services stated the intent was to prevent UTIs and specifically directed staff not to rest the catheter bag on the floor.
Unsanitary Conditions in Kitchen Equipment
Penalty
Summary
The facility failed to maintain food cooking equipment in a clean and sanitary manner, as observed during an inspection of the kitchen. The deep fryer was found to be unclean, with food debris on its metal surfaces and particles floating on top of the cooking oil, which was very dark in color, indicating it had not been changed for some time. The facility cook confirmed the condition of the deep fryer and stated that it had not been used that morning. However, she was unable to recall the last time the deep fryer had been cleaned or the cooking oil changed, suggesting a lack of adherence to a regular cleaning schedule for the cooking equipment.
Failure to Adhere to Fluid Restriction for Resident with Hyponatremia
Penalty
Summary
The facility failed to adhere to a systematic approach to manage fluid restrictions for a resident diagnosed with heart disease, renal disease, high blood pressure, prostate issues, and hyponatremia. The resident was on a physician-ordered fluid restriction of 1000 ml per day, with specific allocations for dietary and nursing staff. However, observations revealed that the resident was provided with a large cup of water containing approximately 473 ml, which exceeded the daily fluid allowance. The resident was not informed about the fluid restriction, and the Certified Nursing Assistant (CNA) assigned to the resident was unaware of the restriction, leading to the resident receiving more fluids than prescribed. The CNA mentioned that there was previously a system of placing stickers on doors to indicate fluid restrictions, but it was unclear if this practice was still in use. Upon reviewing the electronic medical record, the CNA confirmed the fluid restriction but noted that the Kardex did not specify the amount of fluid the resident was to receive. The East Wing Unit Manager also confirmed the fluid restriction and acknowledged that the fluid intake should have been controlled by both dietary and nursing staff. This lack of communication and oversight resulted in the resident receiving excessive fluids, contrary to the physician's orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Titusville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Titusville Rehabilitation & Nursing Center | 3.9 mi | ★★★★★ | 21 | 0 |
| Vista Manor Healthcare And Rehabilitation Center | 3.9 mi | ★★★★★ | 9 | 4 |
| Solaris Healthcare Merritt Island | 14.6 mi | ★★★★★ | 0 | 0 |
| Space Coast Healthcare And Rehabilitation Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Rockledge Healthcare & Rehabilitation Center | 17.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.