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Complaint Investigation

Royal Palms Post Acute

December 23, 2025 · Glendale, CA · 630 W. Broadway
Citations 2
CMS Rating 2/5
Beds 140
Provider ID 055899
Healthcare Facility
Royal Palms Post Acute
Glendale, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

ROYAL PALMS POST ACUTE in GLENDALE, CA — inspection on December 23, 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.

Inspection Findings

FF0627
Resident Rights Deficiencies

During an interview on 1/23/26 at 11:58 AM, the DON stated Resident 1 was brought back to the facility on [DATE]] by a security guard from a local hotel.

The DON stated the facility arranged for Resident 1 to be transferred to the GACH via ambulance transport to evaluate Resident 1's medical condition.

The DON stated Resident 1 was readmitted back to the facility from the GACH on 1/3/26.

During a review of the facility's policy and procedure ( P&P), titled, Transfer of Discharge Documentation, dated 2016, the P&P indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.

Each resident will be permitted to remain in the facility and not be transferred or discharged unless - A. transfer is necessary for the resident's welfare, and the resident's needs cannot be met in the facility. B. transfer or discharge is appropriate because the residents' health has improved sufficiently so the resident no longer needs the services provided by this facility. C. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. D.

The health of individuals in the facility would otherwise be endangered. E.

The resident has failed, after reasonable and appropriate notice, to pay for a stay at this facility.

During a review of the facility's P&P, titled Transfer or Discharge, preparing a Resident for, dated 2016, indicates residents will be prepared in advance for discharge.

When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. A post discharge plan is developed for each resident prior to his transfer or discharge.

This plan will be reviewed with the resident, and family, at least twenty-four hours before the resident's discharge or transfer from the facility.

The business office is responsible for informing appropriate department of the resident's transfer or discharge.

Informing the resident, or his or her representative of our facility' s readmission appeal rights, bed- holding policies.

055899 12/23/2025

Royal Palms Post Acute 630 W.

Broadway Glendale, CA 91204

During another interview on12/23/2025 at 1:39 PM with the DON, the DON stated if the resident returns to the facility, since he had been discharged AMA, the facility will contact the physician and transfer Resident 1 out to the acute hospital emergency room for evaluation.

The DON stated the facility may or may not readmit Resident 1 back.

During an interview on 12/23/2025 at 3:51 PM with the Medical Doctor (MD1), MD1 stated that Resident 1 had an order for an out-on-pass, which required the resident to be accompanied and to return to the facility within four hours . MD1 further stated Resident 1 had a prior history of not returning within the allotted time frame and understood the consequences of failing to return as required.

When asked why there was no documentation regarding behavioral concerns, care plan interventions, interdisciplinary team meetings, revision of privileges, or prior elopement issues, MD1 stated that he allowed repeated opportunities for the resident to return without initiating formal documentation such as care planning or interdisciplinary (IDT) review.

During an interview on 1/23/26 at 11:58 AM, the DON stated Resident 1 did not have a psych eval as ordered on 11/18/25.

The DON stated Resident 1 was brought back to the facility on [DATE]] by a security guard from a local hotel.

The DON stated the facility arranged for Resident 1 to be transferred to the GACH via ambulance transport to evaluate Resident 1's medical condition.

The DON stated Resident 1 was readmitted back to the facility from the GACH on 1/3/26.

During a review of the facility's policy and procedure (P&P) titled Behavioral Assessment, Interventions and Monitoring, the P&P indicated the facility would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

The P&P further indicated the facility's IDT would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly.

The P&P indicated that the resident and the family or representative will be involved in the development and implementation of the care plan.

Interventions will be individualized and part of an overall care environment .

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 GLENDALE, 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 PALMS POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.