Royal Gardens Healthcare: Missed GI Appointment - CA
The physician ordered the gastroenterology appointment for Resident 3 on June 28, 2025. When federal inspectors arrived on August 7 to investigate a complaint, nobody had scheduled it.
During an interview at 3:20 PM on August 7, the director of nursing acknowledged the failure. She stated the gastroenterology order "was missed" and she "was not aware of it."
The admission came with stark warnings about consequences. The director explained that missing appointments "would cause delays in care and services for the residents." She said resident conditions "might get worse and lead to a change in condition and subsequently result in hospitalization."
She added that timely appointments "could potentially prevent exacerbation and worsening of symptoms."
The director outlined who was responsible for scheduling appointments: the case manager, social services director, director of nursing, and nursing staff. She said she had "oversight to make sure appointments were being set up by the facility."
The facility had established a process for handling physician orders. According to the director, staff were supposed to "carry out doctor's orders, set up or schedule the appointments including transportation, record appointments and transportation in the respective binders or logbook."
But when inspectors asked for the written policy governing this critical process, the director could not provide one.
She acknowledged there "should be a policy for setting up appointments, its follow up and endorsement between the departments so no appointments are missed."
The facility's job description for the Central Case Manager, updated December 21, 2022, explicitly assigned responsibility for arranging "transportation and appointment schedules for skilled managed care residents." The case manager was also supposed to manage authorization requests and concurrent review submissions.
Royal Gardens had a written policy titled "Physician Orders" dated April 1, 2023. The policy stated that "whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order."
Despite having both job descriptions and policies outlining appointment scheduling responsibilities, Resident 3's gastroenterology follow-up remained unscheduled 40 days after the physician ordered it.
The director of nursing's acknowledgment that missed appointments could worsen resident conditions and cause hospitalizations underscored the potential impact of the oversight. Her admission that the facility lacked a comprehensive policy for tracking appointments between departments revealed a gap in the system designed to prevent exactly this type of failure.
The inspection found the facility violated federal requirements for following physician orders and providing necessary care and services. The violation affected few residents but carried the potential for actual harm.
For Resident 3, the missed gastroenterology appointment meant more than six weeks without the specialist care their physician deemed necessary. The director's own assessment suggested this delay could lead to deteriorating health and emergency hospitalization that might have been prevented with timely follow-up care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Gardens Healthcare from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ROYAL GARDENS HEALTHCARE in ALHAMBRA, CA was cited for violations during a health inspection on August 11, 2025.
The physician ordered the gastroenterology appointment for Resident 3 on June 28, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.