Facility profile · CCN 145418
Avenues At Royal Oak
71 federal citations on record , including 6 at the Immediate Jeopardy level, and 8 federal enforcement actions totaling $443,531.
Record summary
Federal record · Q1 202671
Total citations
70
Last 3 years
12
Actual harm+
8
Federal penalties
$443,531
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
71 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Jan 13, 2026 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Jan 13, 2026 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Sep 16, 2025 | F847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | F | Standard |
| Sep 16, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Sep 16, 2025 | F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F | Standard |
| Sep 16, 2025 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Standard |
| Sep 16, 2025 | F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Standard |
| Sep 16, 2025 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Sep 16, 2025 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
| Aug 1, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Aug 1, 2025 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Aug 1, 2025 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint |
| May 20, 2025 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | G | Complaint |
| May 20, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Mar 27, 2025 | F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Complaint |
| Mar 27, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Feb 28, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Dec 20, 2024 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F | Complaint |
| Dec 20, 2024 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Dec 20, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Dec 20, 2024 | F567 | Honor the resident's right to manage his or her financial affairs. | E | Complaint |
| Nov 4, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Nov 4, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Sep 25, 2024 | F882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F | Standard |
| Sep 25, 2024 | F881 | Implement a program that monitors antibiotic use. | F | Standard |
| Sep 25, 2024 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Sep 25, 2024 | F760 | Ensure that residents are free from significant medication errors. | G | Standard |
| Sep 25, 2024 | F742 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | D | Standard |
| Sep 25, 2024 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Sep 25, 2024 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Sep 25, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Standard |
| Sep 25, 2024 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Standard |
| Sep 25, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Sep 25, 2024 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Sep 25, 2024 | F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D | Standard |
| Sep 25, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Standard |
| Jul 12, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| May 8, 2024 | F825 | Provide or get specialized rehabilitative services as required for a resident. | D | Complaint |
| Mar 6, 2024 | F825 | Provide or get specialized rehabilitative services as required for a resident. | E | Complaint |
| Feb 14, 2024 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | L | Complaint |
| Feb 14, 2024 | F741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | F | Complaint |
| Feb 14, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Feb 14, 2024 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Complaint |
| Feb 14, 2024 | F622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | J | Complaint |
| Feb 14, 2024 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | K | Complaint |
| Feb 14, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| Feb 14, 2024 | F557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D | Complaint |
| Oct 26, 2023 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Standard |
| Oct 26, 2023 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Standard |
| Oct 26, 2023 | F865 | Have a plan that describes the process for conducting QAPI and QAA activities. | F | Standard |
| Oct 26, 2023 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Oct 26, 2023 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Oct 26, 2023 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard |
| Oct 26, 2023 | F732 | Post nurse staffing information every day. | C | Standard |
| Oct 26, 2023 | F699 | Provide care or services that was trauma informed and/or culturally competent. | D | Standard |
| Oct 26, 2023 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | H | Standard |
| Oct 26, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard |
| Oct 26, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard |
| Oct 26, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Oct 26, 2023 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard |
| Oct 26, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Standard |
| Oct 26, 2023 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | F | Standard |
| Oct 26, 2023 | F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D | Standard |
| Oct 26, 2023 | F577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | F | Standard |
| Oct 26, 2023 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | F | Standard |
| Sep 13, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Sep 13, 2023 | F610 | Respond appropriately to all alleged violations. | L | Complaint |
| Sep 13, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| Jun 24, 2023 | F882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F | — |
| Jun 24, 2023 | F880 | Provide and implement an infection prevention and control program. | F | — |
| Mar 20, 2023 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
Federal enforcement history
Federal regulators have imposed 8 enforcement actions against this facility, including 5 civil money penalties totaling $443,531 and 3 payment-denial actions spanning 130 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| May 20, 2025 | Fine | $33,150 | — |
| Sep 25, 2024 | Payment Denial | — | Oct 19, 2024 · 25 days |
| Sep 25, 2024 | Fine | $72,459 | — |
| Feb 14, 2024 | Fine | $185,705 | — |
| Feb 14, 2024 | Payment Denial | — | Mar 15, 2024 · 67 days |
| Oct 26, 2023 | Payment Denial | — | Nov 21, 2023 · 38 days |
| Oct 26, 2023 | Fine | $115,837 | — |
| Sep 13, 2023 | Fine | $36,380 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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