Royal Palms Post Acute: Missing Resident Failures - CA
Not one.
The Director of Nursing told inspectors that since the resident's admission, she had never been able to reach any family members at all. Emergency Contact No. 1 had no working number. The 3-to-11 shift nurse who discovered the resident hadn't returned tried Emergency Contact No. 2 and couldn't reach him either. The nurse called police. That was the extent of the family notification effort, because there was nothing else available to try.
What made this worse was the paperwork trail that didn't exist. The resident had a physician's order, dated July 23, 2025, that was specific: he could only go out on pass for four hours, for therapeutic purposes, and only with a family member. He went alone. The facility's own records showed no documented evidence that the interdisciplinary team had ever involved family members or the resident's significant other in his care, despite that requirement sitting in his file for five months.
The facility's medical director, identified in the inspection report as MD1, acknowledged during an interview on December 23 that the resident had a prior history of not returning within the required time frame. When inspectors asked why there was no documentation of behavioral concerns, no care plan interventions, no interdisciplinary team meetings, no revision of his pass privileges after previous incidents, MD1's answer was direct: he had allowed the resident repeated opportunities to return without initiating any formal documentation. No care planning. No IDT review. He had simply let it go, each time.
The resident had also been ordered a psychiatric evaluation on November 18, 2025. By the time inspectors interviewed the Director of Nursing on January 23, 2026, that evaluation had never happened.
Royal Palms discharged the resident against medical advice as of December 22, citing that he had decision-making capacity and had left voluntarily, and that he was not considered an elopement risk. The facility's position, in effect, was that this was the resident's own choice and therefore largely his own problem.
He turned up at a local hotel. A security guard brought him back to the facility.
Once he returned, the facility did not simply readmit him. The Director of Nursing told inspectors that because he had been discharged against medical advice, the facility's plan was to contact his physician and transfer him to an acute hospital emergency room for evaluation first, and that the facility may or may not readmit him at all. He was transferred to the hospital by ambulance and readmitted to Royal Palms on January 3, 2026.
The inspection was a complaint survey, conducted December 23, 2025. Inspectors classified the level of harm as minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory category, not the experience of a dialysis patient who spent days unaccounted for while the facility held a file full of phone numbers that didn't work and a physician's order that hadn't been followed in months.
The facility's own behavioral assessment policy, reviewed by inspectors, stated that the interdisciplinary team would evaluate behavioral symptoms to determine severity, distress, and potential safety risk, and would develop a care plan accordingly. It stated that the resident and family would be involved in developing and carrying out that plan. Interventions would be individualized.
None of that had happened for this resident. The physician said so himself.
A man on dialysis, with a documented history of not coming back when he was supposed to, was sent out alone to a medical appointment he never attended. His family couldn't be reached because no one at the facility had ever been able to reach them, and there is no record that anyone formally addressed that problem either. He ended up at a hotel. A security guard found him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Palms Post Acute from 2025-12-23 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: August 22, 2026 · Our methodology
ROYAL PALMS POST ACUTE in GLENDALE, CA was cited for violations during a health inspection on December 23, 2025.
The Director of Nursing told inspectors that since the resident's admission, she had never been able to reach any family members at all.
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.