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Complaint Investigation

Royal Gardens Healthcare

August 21, 2025 · Alhambra, CA · 2339 W. Valley Blvd.
Citations 2
CMS Rating 2/5
Beds 43
Provider ID 055818
Healthcare Facility
Royal Gardens Healthcare
Alhambra, CA  ·  View full profile →
Inspection Summary

ROYAL GARDENS HEALTHCARE in ALHAMBRA, CA — inspection on August 21, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0627
Resident Rights Deficiencies
Potential for More Than Minimal Harm

any reason that all special instructions or precautions for ongoing care as appropriate such as treatments and devices (oxygen) should be conveyed to the receiving provider to ensure a safe and effective transition of care.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Royal Gardens Healthcare

2339 W.

Valley Blvd.

Alhambra, CA 91803

SUMMARY STATEMENT OF DEFICIENCIES

During a concurrent interview and record review on 8/18/2025 at 3:30 PM with the Director of Nursing (DON) of Resident 1's Notice of Transfer/Discharge, the DON stated staff usually signed the form, but Registered Nurse 1 (RN 1) forgot to have the resident sign the form.

The DON stated the Notice of Transfer/Discharge was the only document residents signed when they were discharged .

During an interview on 8/18/2025 at 4:50 PM with RN 2, RN 2 stated the Notice of Transfer/Discharge was signed by RN 1 and this meant that the resident was notified about the details of the Notice of Transfer/Discharge and information such as the discharge location, their belongings, and medications. RN 2 stated the Notice of Transfer/Discharge should be signed by the resident or responsible party.During a concurrent record review of Resident 1 and Resident 2's Notice of Transfer/Discharge forms and interview with the DON on 8/18/2025 at 5:03 PM, the DON stated both forms did not have the residents' signatures.

The DON stated the forms should be signed by the residents for legal purposes and proper documentation.

During a record review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised 7/2017, the policy indicated documentation in the medical record will be objective, complete, and accurate.

During a record review of the facility's P&P titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, the policy indicated when a resident is transferred or discharged from the facility, the following information is documented in the medical record: that an appropriate notice was provided to the resident and/or legal representative.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ALHAMBRA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ROYAL GARDENS HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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