Health inspection·August 11, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two (2) of 2 residents were seen by specialty doctor as indicated on the physician's order when the facility failed to:1. Follow up and obtain a prior authorization (process where healthcare providers must obtain advance approval from a patient's insurance company before providing certain medical services or medications), on a weekly basis, for Resident 1 to be seen by Vascular Surgery (treats diseases of the blood vessels, including arteries [blood vessels carrying oxygen rich blood away from the heart to the rest of the body], veins [blood vessels that carry blood from the body's tissues and organs back to the heart], and lymphatic vessels [network of thin tubes that collect excess fluid, called lymph, from body tissues and return to the blood stream [blood as it moves through the body's). 2. Set up the medical appointment for gastroenterology (GI-medical specialty that focuses on the study, diagnosis, and treatment of disorders affecting the digestive system [including the esophagus, stomach, small and large intestines, rectum, liver, gallbladder, and pancreas]) for Resident 3. This deficient practice had the potential to result in a delay of treatment and necessary services for Resident 1 and Resident 3, which could negatively affect the residents' overall wellbeing.Findings: 1 During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/5/2025 with diagnoses that included, but not limited to acute osteomyelitis (infection of the bone that causes inflammation and damage) of the right ankle [the joint that connects the foot to the leg] and foot, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), diabetic neuropathy (type of nerve damage caused by diabetes), and diabetic foot ulcer (a break in the skin of the foot that doesn't heal properly). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1 had moderate impairment in cognitive (mental abilities used for thinking, learning, remembering, and problem solving) skills for daily decision making. The MDS indicated Resident 1 was independent with eating. The MDS indicated Resident 1 required set up or clean up assistance (Helper sets up or cleans up; resident completes the activity. Helper assists only prior to or following the activity) with oral and personal hygiene. The MDS also indicated Resident 1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with toileting hygiene and upper body dressing. The MDS further indicated Resident 1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with showering/bathing self, lower body dressing and putting on/taking off footwear. During an interview on 8/7/2025 at 2:38 PM with Registered Nurse Supervisor (RN 1), RN 1 stated that Social Services Specialist or Designee (SSD-entry-level professional, typically in long term care facilities, who support residents by assessing their social, emotional, and spiritual needs, developing care plans, and coordinating access to necessary services and Residents Affected - Few Page 1 of 4 055818 055818 08/11/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resources) and Nursing staff work on resident appointments if they have Medicare (federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions) insurance as Medicare residents do not require prior authorizations for appointments such as for follow up or consultation with specialty doctors. RN 1 stated that if residents have Medi-cal (federal Medicaid program in California) insurance contracted with managed care plans, like Health Maintenance Organizations (HMO-type of health insurance plan that provides coverage for care only from doctors, hospitals, and providers within its specific network), it was the Case Manager (CM-health care professional, often a nurse or SW, who coordinates and manages the care of individuals, ensuring they receive the necessary services and support) who oversaw appointment set up because they needed prior authorizations from the Independent Physician Association (IPA-a network of independent doctors and specialists who contract with managed care plans or HMOs, to provide services to their members). During a record review of the Order Summary dated 7/22/2025, the Order Summary indicated: Follow up appointment with and treatment of right ankle osteomyelitis at Vascular Surgeon, ordered on 5/19/2025. During an interview on 8/7/2025 at 3 PM with RN 1, RN 1 stated that Resident 1 had Medi-cal insurance, and the CM was working on the authorization for Resident 1's Vascular surgery consult. RN 1 stated the authorization status was still pending as verbally endorsed by CM. During a concurrent interview and record review on 8/11/2025 at 11:59 AM with the CM, the CM notes dated 5/19/2025, 5/22/2025, 6/16/2025, 6/17/2025, 6/19/2025, and 6/24/2025 were reviewed. CM notes indicated: 5/19/2025 at 3:01 PM: Vascular consult authorization request faxed to the IPA for approval. Resident 1's family was updated. 5/22/2025 at 3:56 PM: Authorization was approved. Called Vascular clinic for appointment, no answer. Resident 1's family updated. 5/22/2025 at 4:16 PM: Faxed documents to Vascular clinic. Pending review. Vascular clinic will call facility for appointment after review. 6/16/2025 at 4:05 PM: Called IPA Utilization Management (UM- manages and monitors the use of healthcare resources to ensure patients receive medically necessary, appropriate, and high-quality care at a cost-effective level) Department, authorization modification request followed up. Still pending and under review. 6/17/2025 at 4:01 PM: called UM department, modification of authorization still pending. Will continue to follow up on status. 6/19/2025 at 4:26 PM: Called IPA to follow up, office closed. Will call in the morning to follow up. 6/24/2025 at 11:42 AM: called IPA UM department. Request still pending for vascular consult; emailed urgent msg to reviewer aware multiple calls have been made to req modification-CM told to call back in the morning. 6/24/2025 at 12:45 PM: Podiatrist (medical specialists who treats the feet and their ailments) Consultation authorization request. Called Podiatrist clinic to set up appointment but clinic manager stated prior authorization was needed. Request submitted to the IPA. Pending at this time. Communicated with nursing.The CM stated that she has been following up the status of the prior authorization request with the IPA weekly. CM stated that the last time she followed up with the IPA was on 7/1/2025 and was told to call again as authorizations were still under review. CM stated she did not and should have documented the 7/1/2025 follow up. Upon review of the progress notes documentation, the CM stated she did not and should have followed up on a weekly basis as routinely done for physician's orders such as follow up/ consult with specialty doctor. CM stated she should have escalated the situation to her supervisor or notified the primary physician or medical director of other recommendations and to see if they can assist with contacting the IPA. The CM stated she only comes to the facility weekly. CM stated there were no follow ups done to obtain an authorization after 7/1/2025 to ensure Resident 1 was seen by vascular surgeon as indicated on the physician's order. The CM stated that she endorsed this to the Director of Nursing (DON) and RN 1 before 6/24/2025 but cannot recall the date and time as she did not document this in her progress 055818 Page 2 of 4 055818 08/11/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notes. The CM stated that this potentially caused a delay in the care and services that Resident 1 needed. The CM stated that if Resident 1 was seen by the vascular specialist, this could potentially have prevented worsening of the wound. During a concurrent interview and record review on 8/11/2025 at 1:30 PM with the Licensed Vocational Nurse/Treatment Nurse (LVN 1), the change in condition (COC) documentation dated 6/8/2025 was reviewed. The COC documentation indicated there was a fluid filled blister on Resident 1's right lateral (to the side or sideways) malleolus (bony prominence on each side of the human ankle) surgical site and the site was dehisced (the splitting or bursting open of a surgical wound). LVN 1 stated the right lateral malleolus surgical site was observed dehisced and the primary physician and wound care Nurse Practitioner (NP-an advanced practice registered nurse who has completed advanced education and clinical training beyond their initial nursing degree) were notified. LVN 1 stated the wound NP came to assess Resident 1 on 6/9/2025 and recommended Resident 1 be evaluated by the Surgeon (medical practitioner qualified to practice surgery) who performed the surgery on his right lateral malleolus. LVN 1 stated that on 6/13/2025, the order was obtained from primary physician to have Resident 1 evaluated by the surgeon During an interview on 8/11/2025 at 3 PM with the DON, the DON stated the facility did not but should have a policy and procedure (P&P) on communication between facility departments and appointment scheduling to ensure Resident appointments are not missed or delayed since the facility staff would know what to do and follow up for communication/ endorsement process, appointment scheduling, and requirements needed to facilitate scheduling. The DON stated that missed or delayed appointments could negatively affect the residents' overall health and wellbeing potentially leading to worsening of conditions, prolonged hospitalizations and even death. During an interview on 8/11/2025 at 4:15 PM with the Administrator (ADM) and DON, the ADM stated that CM was scheduled to be in the facility weekly but available everyday by phone or email. The ADM stated that the CM can make phone calls to follow up with the IPA everyday even if she was not physically in the facility. The ADM stated that not being in the facility was not an excuse for not being able to make the follow-up calls to the IPA. 2 During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 6/16/2025 and readmitted on [DATE]with diagnoses including but not limited to DM, diabetic autonomic polyneuropathy (damage to the autonomic nerves [nerve that is part of the autonomic nervous system and controls involuntary bodily functions such as heart rate, digestion, breathing, and sweating] caused by DM), gastrointestinal hemorrhage (bleeding from anywhere within the gastrointestinal tract, which includes the esophagus, stomach, small and large intestine, rectum and anus), and Gastro esophageal reflux disease (GERD-condition where stomach contents flow back up into the esophagus, causing irritation and discomfort). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS indicated Resident 3 required set up or clean up assistance with oral hygiene. The MDS indicated Resident 3 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating. The MDS indicated Resident 3 required partial/moderate assistance with upper body dressing, required substantial/maximal assistance with lower body dressing and was dependent with toileting hygiene and shower/bathing self.During a record review of the doctor's order dated 6/28/2025, the doctor's order indicated: Appointment with GI in two to three weeks. During a concurrent interview and record review on 8/7/2025 at 2:38 PM with RN 1, the Order Summary from 6/27/2025 to 8/7/2025 was reviewed. The Order Summary indicated to set up appointment for GI in 2 to three (3) weeks, ordered on 6/28/2025. RN 1 stated nursing staff or SSD who were expected to have worked on setting up Resident 055818 Page 3 of 4 055818 08/11/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3's appointment, did not work on it. During an interview on 8/7/2025 at 3:20 PM with the DON, the DON stated the GI order for follow up appointment ordered on 6/28/2025 for Resident 3 was not done. The DON stated that the order was missed, and she was not aware of it. The DON stated that it was important to set up the appointments ordered by the physician. The DON stated that if appointments were not set up, this would cause delays in care and services for the residents. The DON stated that resident conditions might get worse and lead to a change in condition and subsequently result in hospitalization. The DON stated if appointments were made timely, this could potentially prevent exacerbation and worsening of symptoms. The DON stated CM, SSD, DON and Nursing staff could and were expected to set up appointments and the DON had the oversight to make sure appointments were being set up by the facility. The DON stated there was a process, which was to carry out doctor's orders, set up or schedule the appointments including transportation, record appointments and transportation in the respective binders or logbook. The DON stated the staff follow this process but could not provide a policy. The DON stated there should be a policy for setting up appointments, its follow up and endorsement between the departments so no appointments are missed. During a review of the Job Description titled, Central Case Manager, updated 12/21/2022, the job description indicated the duties and responsibilities of the central CM included: Manage all existing authorizations through concurrent review submissions and process new authorization requests for significantly involved provider (SIP-refers to a provider who actively participated in a patient's care during a specific episode, regardless of standard of care determination) and/or Managed Care Part B services. Arrange transportation and appointment schedules for skilled managed care residents. During a review of the facility's Policy and Procedure (P&P) titled Physician Orders, dated 4/1/2023, the P&P indicated that whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. 055818 Page 4 of 4