Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Park Rehabilitation & Health Center during CMS and state inspections, most recent first.
A resident with a history of hydronephrosis and urological cancer had a urinary catheter removed by facility staff contrary to hospital discharge orders, leading to reinsertion, improper placement, and subsequent trauma requiring hospitalization. Staff did not reconcile the hospital discharge summary with EMR orders, resulting in the deficiency.
Surveyors found that staff did not consistently label, date, or discard expired food items in two nourishment rooms. Unlabeled and expired items such as coffee creamer, noodles, iced tea, prune juice, and pudding were observed. The Dietary Manager confirmed that all items should be labeled and expired items discarded, but checks were missed and procedures were not consistently followed.
A resident admitted for respite care with multiple chronic conditions did not receive several prescribed medications for multiple days due to the facility's lack of effective systems for obtaining and administering medications. Staff and pharmacy interviews revealed confusion and inconsistent procedures, resulting in numerous missed doses documented on the MAR.
Multiple residents consistently received meals that were not at appropriate temperatures, with hot foods served lukewarm or cold and beverages sometimes partially frozen. Residents and staff reported frequent reheating of meals, dissatisfaction with food quality, and ongoing complaints to facility leadership. Observations confirmed that food was often not served as ordered and lacked proper temperature control.
A resident with a gastrostomy tube and complex medical history received enteral feedings using a syringe that was not properly washed or dried after use. An RN stored the wet syringe with the plunger inside and residual formula present in a plastic bag at the bedside, contrary to facility protocol. Staff interviews confirmed a lack of awareness regarding the need to separate and air dry the syringe and plunger to prevent bacterial growth.
Surveyors identified an 11.5% medication error rate after observing three errors during medication administration. Errors included a resident with renal disease receiving sevelamer before the scheduled meal instead of with meals as ordered, and two residents receiving single-ingredient sennosides instead of the prescribed sennosides/docusate combination. Staff involved acknowledged the discrepancies after reviewing orders and medication labels.
A resident who was cognitively intact and had documented dislikes for certain breakfast items repeatedly received those items despite expressing her preferences for alternatives like yogurt to both dietary and nursing staff. Staff interviews revealed ongoing issues with tracking food preferences due to software problems, and communication lapses prevented the resident's preferences from being honored.
Two residents had inaccuracies in their MDS assessments: one was incorrectly coded as discharged to home when actually sent to the hospital, and another receiving hospice care was incorrectly coded as not having a prognosis of six months or less, despite physician documentation.
A resident was observed taking medications unsupervised, despite not being assessed for self-administration. The resident, who was cognitively intact, had medications left at the bedside on multiple occasions. Interviews revealed that the facility's protocol requires an assessment for self-administration, which was not conducted for this resident.
A nurse failed to follow the infection control policy by not performing hand hygiene after removing soiled dressings and before donning new gloves during wound care for a resident. Despite the facility's policy requiring hand hygiene after glove removal, the nurse changed gloves multiple times without sanitizing hands. Interviews with the nurse, Infection Preventionist, and Director of Nursing confirmed the expectation for hand hygiene, with the nurse attributing the lapse to forgetfulness.
A resident's oxycodone medication was misappropriated by a nurse, who forged a Medication Aide's signature to remove the drugs from the medication cart. The facility's investigation confirmed the nurse's involvement through video footage, leading to her termination. The resident continued to receive her medication without delay, and the facility implemented corrective measures to prevent future incidents.
Failure to Follow Hospital Discharge Orders for Urinary Catheter Management
Penalty
Summary
A deficiency occurred when the facility failed to follow hospital discharge orders regarding urinary catheter management for a resident with a complex urological history, including hydronephrosis, prostate and bladder cancer, and a recent sacral fracture. The hospital discharge summary specified that the urinary catheter was to remain in place until a follow-up with urology, but facility staff removed the catheter for a voiding trial based on orders entered into the electronic medical record (EMR). This removal was performed despite concerns voiced by the resident and their representative, who were informed by the nurse that the order to remove the catheter originated from the hospital. Within hours, the facility determined that the catheter should not have been removed and reinserted it per the Medical Director’s review of the hospital records. Following reinsertion of the urinary catheter, the resident began experiencing lower abdominal pain and blood in the catheter tubing. Nursing staff observed string-like blood clots and visible bleeding from the urethral meatus, prompting notification of the on-call provider and subsequent transfer to the emergency department (ED). The hospital urologist found that the catheter had not been advanced properly, with the balloon inflated in the prostate, resulting in trauma to the urethra and the creation of a false passage. The resident required cystoscopy for proper catheter placement, constant bladder irrigation, and antibiotics during a week-long hospitalization. Interviews with facility staff revealed that the discharge summary scanned into the EMR did not match the one reviewed by the nursing supervisor and nurse practitioner, leading to the incorrect order for catheter removal. The nurse who performed the removal did not compare the hospital discharge summary sent with the resident to the EMR orders, relying instead on the orders already verified and entered. The Medical Director and hospital urologist both confirmed that the catheter should have remained in place, and the urologist stated that the resident’s history made catheterization particularly difficult, suggesting that reinsertion should have been performed in a hospital setting.
Failure to Label, Date, and Discard Expired Food Items in Nourishment Rooms
Penalty
Summary
Surveyors observed that staff failed to consistently label and date food items and discard expired products in two of three nourishment rooms. Specifically, in the 300/400 hall nourishment room, there was an opened container of coffee creamer labeled with a name but no date, a container with noodles labeled with a resident's name but no date, a gallon of iced tea not labeled with the product or resident name and with a best by date that had already passed, and an opened bottle of prune juice not labeled with a resident's name. In the 500/600 hall nourishment room, a container of leftover pudding was found without any label or date. These findings were confirmed during interviews with the Dietary Manager, who stated that all items were expected to be labeled and expired items discarded. Further interviews revealed that although kitchen staff were supposed to check the nourishment rooms twice daily, the Assistant Dietary Manager admitted to not checking the rooms on a specific day when she was working as a dietary aide and forgot to perform the check. The Director of Nursing and the Administrator both stated that staff were educated to label and date residents' items in the nourishment rooms and that this was covered during orientation. However, the observations indicated that these procedures were not consistently followed, resulting in the presence of unlabeled and expired food items.
Failure to Provide Timely Medications for Respite Care Resident
Penalty
Summary
The facility failed to have effective systems in place to obtain and provide medications for a newly admitted respite care resident, resulting in multiple missed doses of eleven prescribed medications. The resident, who had complex medical needs including end stage renal disease requiring dialysis, glaucoma, GERD, and dementia, was admitted for a short-term stay. Despite having clear physician orders for a range of medications, including eye drops, oral medications, and a phosphate binder, the facility did not ensure these medications were available and administered as ordered. Nursing notes and interviews revealed that the resident's medications were not received or administered for several days after admission. Staff reported confusion regarding the process for obtaining medications for respite care residents, particularly those enrolled in a managed care program. The contracted pharmacy did not receive requests to fill the resident's medications until several days after admission, and the managed care pharmacy did not provide medications for respite stays. As a result, the resident missed multiple doses of critical medications, as documented in the Medication Administration Record (MAR), with many doses left blank, held, or otherwise not given. Interviews with nursing staff, the DON, and pharmacy representatives confirmed a lack of clarity and established procedures for obtaining and administering medications to respite care residents. The facility's staff gave inconsistent answers about whether medications should be brought from home or obtained from the contracted pharmacy, and there was no evidence that a consistent or effective process was followed. The resident's vital signs remained stable during the stay, and no harm was identified by the nurse practitioner, but the deficiency was due to the facility's failure to ensure medications were available and administered as ordered.
Failure to Serve Food and Beverages at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages were served at palatable and safe temperatures, resulting in multiple residents receiving lukewarm or cold hot foods and partially frozen beverages. Observations and interviews revealed that residents consistently received meals that were not at the appropriate temperature, with several residents reporting that their food was often cold upon delivery. Staff frequently offered to reheat food, but some residents declined due to concerns about food quality after reheating, such as eggs becoming too dry and difficult to chew. In some cases, residents expressed frustration and hesitancy to eat meals due to the persistent issue of cold food. Residents with various dietary orders, including cardiac, diabetic, pureed, and regular diets, were affected by the deficiency. Cognitively intact residents repeatedly voiced concerns about the temperature and quality of their meals, with some reporting that their complaints had been raised to the Resident Council and facility administration over several months without improvement. Observations included instances where hot foods arrived without visible steam, beverages were served cold or partially frozen, and meal items did not match the tray tickets. Staff interviews confirmed that reheating food was a common practice, and administrative staff were also involved in meal delivery and setup. Facility leadership, including the Dietary Manager, DON, and Administrator, acknowledged awareness of ongoing complaints regarding food temperature and palatability. The Dietary Manager stated that replacement trays should be offered instead of reheating, but there was no documented evidence of daily test tray records. Staff reported that meal trays were delivered promptly upon arrival to the units, yet the issue persisted, with many trays requiring reheating. The deficiency was further substantiated by staff and resident interviews, as well as direct observations of meal service and food temperatures.
Improper Storage and Handling of Enteral Feeding Syringe
Penalty
Summary
A deficiency was identified regarding the management of enteral feeding equipment for a resident with multiple medical conditions, including diabetes, stroke, malnutrition, and gastrostomy status. The resident was receiving scheduled bolus feedings and water flushes through a gastrostomy tube. During observations, it was noted that the syringe used for enteral feedings and medication administration was stored with the plunger inside the syringe, wet with condensation, and placed in a plastic bag on the bedside table. After administering a feeding and water flush, the nurse did not separate or wash the syringe and plunger, instead placing them back in the bag with residual formula present. Staff interviews revealed that the nurse was unaware of the requirement to dry the syringe and plunger separately to prevent bacterial growth, although she acknowledged the need to wash the syringe if residue was present. The DON confirmed that the protocol required washing and air drying the syringe and plunger separately, and that staff had been educated on this process. The administrator also stated that the nurse should have washed and dried the equipment properly to prevent bacterial growth.
Medication Error Rate Exceeds 5% Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 26 observed opportunities, resulting in an 11.5% error rate. Surveyors observed medication administration to five residents and identified errors involving three residents. The errors were identified through direct observation, staff interviews, and review of medication orders and administration records. One resident with end stage renal disease requiring hemodialysis was administered sevelamer, a phosphate binder, at a time not consistent with the physician's order, which specified the medication should be given with meals. The nurse administered the medication well before the scheduled dinner meal, providing only juice and crackers instead of a full meal, and was unaware that the medication was intended to be given specifically with meals. This action did not align with the prescribed instructions or the manufacturer's guidelines. Two other residents were administered a single ingredient medication containing only sennosides, rather than the prescribed combination medication of sennosides and docusate. In both cases, the staff members selected the incorrect medication from the stock bottles on the medication cart, failing to match the medication to the physician's order. Both the nurse and the medication aide involved acknowledged the error after reviewing the orders and the available medications, confirming that the combination medication should have been administered as ordered.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences, resulting in the resident repeatedly receiving breakfast items she disliked, specifically hot cereal and grits. The resident, who was cognitively intact according to her most recent MDS assessment, had an undated preference sheet indicating a dislike for grits and hot cereal and had communicated her preference for yogurt to both dietary and nursing staff on multiple occasions. Despite these communications, observations on two separate mornings confirmed that she continued to receive the unwanted food items. Interviews with staff revealed ongoing issues with tracking and honoring residents' food preferences. The nurse interviewed stated she had relayed the resident's concerns to dietary staff but could not recall to whom. The Dietary Manager acknowledged problems with the facility's meal program software, which contributed to the inability to consistently provide residents with their preferred food items. The DON was unaware of the issue, and the Administrator reported that no concerns had been brought to her attention, despite the resident's repeated complaints.
Inaccurate MDS Coding for Discharge and Hospice Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of discharge and hospice status. For one resident, the discharge MDS was coded as a discharge to home based on information from the responsible party that the resident was sent home from the hospital and would not return to the facility. However, the resident had actually been sent to the hospital for evaluation following an episode of sudden confusion and shaking, and the discharge MDS did not accurately reflect the resident's discharge location from the facility. For another resident with Alzheimer's dementia and rheumatoid arthritis, who was under hospice care, the quarterly MDS assessment was incorrectly coded regarding the resident's prognosis. Although the hospice plan of care and physician documentation indicated a prognosis of six months or less, the MDS was coded as 'no' for this item. The MDS Coordinator acknowledged the error, stating it was a mistake and that the assessment should have been coded correctly.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of a resident, identified as Resident #42, to self-administer medications. Resident #42, who was cognitively intact according to the Minimum Data Set, was observed with a cup of medications left at his bedside on multiple occasions. Despite the resident's assertion that he knows his medications and takes them independently, there was no documented assessment or care plan focus area for self-administration of medications. The Medication Administration Record indicated that a medication aide had signed off on administering several medications to the resident, but the resident was observed taking the medications without supervision. Interviews with the medication aide and the Director of Nursing revealed that the facility's protocol requires a physician's order and an assessment for residents to self-administer medications. The medication aide admitted to leaving the resident with medications unsupervised, contrary to the facility's policy. The Director of Nursing confirmed that Resident #42 had not been assessed for self-administration and should have been supervised during medication administration. This lack of assessment and supervision led to the deficiency identified in the report.
Infection Control Policy Violation During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policy during wound care procedures, as observed in the actions of Nurse #1. During a continuous observation of wound care, Nurse #1 did not perform hand hygiene after removing soiled dressings and before donning new gloves. This occurred multiple times during the care of a resident with wounds on the left upper back and right heel. The facility's policy clearly states that hand hygiene should be performed after contact with body fluids, non-intact skin, wound dressings, and after removing gloves. Despite this, Nurse #1 was observed to change gloves several times without sanitizing her hands in between, which is a direct violation of the facility's infection control policy. Interviews with Nurse #1, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed the expectation for hand hygiene to be performed after glove removal. Nurse #1 acknowledged her lapse in hand hygiene, attributing it to forgetfulness during the procedure. The IP confirmed that hand hygiene should be done after each glove change and noted that education on infection control, including hand hygiene, was provided to staff. However, the IP had not directly observed Nurse #1's wound care practices. The DON reiterated the importance of hand hygiene after glove removal, indicating that staff education on infection control is regularly conducted.
Misappropriation of Controlled Medications by Nurse
Penalty
Summary
The facility failed to protect a resident's rights by allowing the misappropriation of controlled medications. The incident involved a resident who was prescribed oxycodone for knee pain. The medication was found to be missing from the medication cart, along with the controlled medication count sheet. The facility's investigation revealed that Nurse #2 was allegedly responsible for removing the medication and the count sheet from the cart. Despite several attempts to contact Nurse #2, she did not respond, and video footage later confirmed her involvement in the diversion of the drugs. The investigation showed that Nurse #2 had forged the signature of a Medication Aide to sign out two medication cards, which included the missing oxycodone tablets. The facility's former Director of Nursing (DON) conducted a thorough audit of pharmacy packing slips, medication administration records, and controlled medication return sheets, confirming that 24 tablets of oxycodone were missing. The incident was reported to the Department of Health and Human Services, law enforcement, the North Carolina Board of Nursing, and Adult Protective Services. The affected resident was assessed and did not experience any adverse effects from the missing medication, as the facility promptly replaced the missing doses. Interviews with staff and the resident confirmed that the resident continued to receive her medication as prescribed without any delays. The facility took immediate action to address the issue, including terminating Nurse #2 and conducting in-service training for all nursing staff on narcotic accountability and the prevention of drug diversion. The facility also implemented a monitoring procedure to ensure compliance with controlled substance processes, which was reviewed by the Quality Assurance Performance Improvement Committee.
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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 Matthews
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court Sc Ctr At Matthews Glen | 0 mi | ★★★★★ | 4 | 0 |
| Matthews Health & Rehab Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Lake Park Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 11 | 0 |
| Brookdale Carriage Club Providence | 5.3 mi | ★★★★★ | 1 | 0 |
| Sardis Oaks | 6.3 mi | ★★★★★ | 4 | 0 |
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