Camellia Gardens Care Center: Readmission Failure - CA
The resident, identified in inspection records only as Resident 1, had been hospitalized and was ready to return to the facility as early as December 18, 2025. The hospital's case manager had been calling and waiting for a bed. The facility's own daily census reports, reviewed by inspectors on December 24, showed that Room A, a four-bed room, had three open beds every single day from December 18 through December 24. The resident did not return until after inspectors arrived.
The breakdown wasn't a shortage of space. It was a chain of people who each assumed someone else had handled it, and nobody had.
The admissions coordinator, identified in the report as AC, had been telling the hospital's case manager since December 18 that no isolation bed was available, and that the facility could not admit Resident 1. She had been saying this, inspectors found, since November 4. When inspectors interviewed her on December 24, she said she did not know why she had not asked the director of nursing or the infection preventionist whether a room could be arranged. "I did not inquired with the DON nor IPN about room availability," she told inspectors, adding that she should have relayed the information about the pending admission and the isolation requirement to both of them.
The infection preventionist nurse, interviewed the same day, said she had no idea the hospital had cleared Resident 1 for discharge back to the facility with contact isolation precautions. She said if she had known, she could have moved residents around and made a bed available from December 18 onward. She confirmed the resident met the facility's readmission criteria the entire time.
The director of nursing reviewed the same census reports with inspectors and reached the same conclusion. She said she could have made room changes and moved a resident out of Room A to accommodate Resident 1 starting December 18. She did not dispute the timeline.
What she did on the evening of December 24 made the situation worse. She called the hospital to confirm whether Resident 1 was still there. The resident was. She spoke with a registered nurse at the hospital. She did not mention that the facility now had a bed available. She told inspectors on December 26 that she should have let the hospital know about the opening so the admission could happen without further delay.
The hospital's case manager, reached by phone on December 29, told inspectors he had started asking about readmission on December 18. The admissions coordinator had told him repeatedly there was no bed. He had kept asking. The answer had stayed the same.
The admissions coordinator's own job description, reviewed by inspectors, lists as an essential function: maintaining updated bed availability information at all times, managing the inquiry process professionally and with appropriate follow-up, and working closely with the director of nursing to ensure appropriate and efficient decisions about admissions. A facility policy on readmission, last revised in March 2017, states that residents discharged to the hospital will be given priority for readmission upon the first availability of a bed.
The gap between those written commitments and what actually happened from December 18 to December 24 is what inspectors documented.
Resident 1 had Candida auris, a drug-resistant fungal infection that spreads easily in healthcare settings and requires contact isolation precautions. The hospital had determined the resident was stable enough to leave. The facility had the space. The infection preventionist said she could have managed the isolation. What the facility did not have, for six days, was anyone who asked the question that would have made the difference.
The inspection was conducted as a complaint investigation. Inspectors classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. The resident remained at the hospital through at least the date inspectors completed their review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Camellia Gardens Care Center from 2025-12-26 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 21, 2026 · Our methodology
CAMELLIA GARDENS CARE CENTER in PASADENA, CA was cited for violations during a health inspection on December 26, 2025.
The resident, identified in inspection records only as Resident 1, had been hospitalized and was ready to return to the facility as early as December 18, 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.