Health inspection·January 13, 2026

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 provide the necessary care and services in accordance with the standards of practice for one of three sample residents (Resident 1) by failing to: Relay to Resident 1's physician and obtain an order regarding ST (Speech Therapist's- a professional who assesses, diagnoses, and treats swallowing disorders in people of all ages, helping them to have a safe eating through individualized therapy plans) recommendation to assist the resident during mealtime to enhance safe swallow. Relay to Resident 1's physician and obtain an order for ST evaluation after Resident 1 was observed and assessed to be able to feed himself without 1:1 assistance from the staff from 11/17/2025 to 12/19/2025. This deficient practice placed Resident 1 at-risk for aspiration (food, liquid, saliva, or other foreign material accidentally enters their airway and lungs instead of going down the esophagus (food pipe) into the stomach which can lead to serious injury and/ or death. Findings: A review of an admission Records indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, and aphagia (difficulty swallowing food or liquid) oropharyngeal (throat) phase. A review of the Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, indicated Resident 1 is assessed to be cognitively (a mental process of acquiring knowledge and understanding) impaired. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for eating. 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, but provides less than half the effort) on staff for oral hygiene and personal hygiene. A review of Resident 1's Physician Order dated 12/22/2025 at 10:56 PM, indicated that Resident 1 needed 1:1 (dedicated, personalized support from one staff member to one individual to provide assistance) feeding during meals to prevent aspiration. There was no physician order dated from 11/16/2025 to 12/21/2025 that Resident 1 needed 1:1 feeding during meals to prevent aspiration. During a record review of Resident 1's SLP (Speech-Language Pathologist) Evaluation and Plan of Treatment (SLPE&PT), dated 11/16/2025, it indicated Resident is currently on three meals with assistance of feeding to enhance safe swallow. There was no documented evidence or SLPE&PT form that the ST have reevaluated Resident 1's need for feeding assistance from 11/17/2025 to 12/19/2025. A review of Resident 1's care plan, titled Risk for Aspiration initiated dated 11/18/2024 and revised on 12/18/2025, the care plan indicated interventions included staff to monitor Resident 1's for signs and symptoms of aspiration, prompt intervention, and inform the physician. A review of Resident 1's care plan, titled Swallowing problem initiated dated 12/4/2025 and revised on Residents Affected - Few Page 1 of 2 055818 055818 01/13/2026 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 12/18/2025, the care plan indicated Resident 1 had history of swallowing problem. The care plan indicated intervention included Certified Nurse Assistant (CNA) to check Resident 1's mouth after meal for pocketed food and debris and to report to nurse. During a concurrent observation and interview on 1/6/2026 at 12:36 PM, with CNA 1 in Resident 1's room, Resident 1 was sitting in bed with the head-of-bed elevated. CNA 1 stood on the right side of the bed while Resident 1 was eating by himself. CNA 1 stated Resident 1 has been able to feed himself (unable to recall since when). CNA 1 also stated, she did not know if Resident 1 being able to feed himself was relayed to Resident 1's physician. During an interview with Rehabilitation Nurse Assistant (RNA) on 0/6/2026 at 1:50 PM, RNA was told by the charge nurse that Resident 1 needs 1:1 feeding assistance. RNA also stated RNA 1 observed and noted Resident 1 is able to feed himself but for a while now. During an interview with Registered Nurse (RN) on 1/6/2026 at 2:19 PM, RN stated Resident has been able to feed himself. RN stated, if Resident 1 is able to feed himself and only need supervision, it should have been relayed to Reisdent 1's physician to obtain an order for ST reevaluation in that way Resident 1 can be re- evaluated by ST to ensure the facility is providing the feeding assistance that the resident need, whether supervision only or 1:1 assistance to prevent aspiration. RN stated, there was no documented evidence ST reevaluated Resident 1 for the kind of assistance needed during mealtime from 11/17/2025 to 12/19/2025. During an interview on 1/13/2026 at 11:18 AM, with the Administrator (ADM), ADM stated facility should clarify ST's recommendation dated 11/16/2025, relayed it to Resident 1's physician to obtain an order for feeding assistance to Resident 1 and added it in Resident 1's care plan to ensure the facility staff are providing the appropriate feeding assistance to Resident 1. ADM also stated if facility staff have observed/ assessed Resident 1 is able to feed himself with supervision from staff, the licensed nurse should have relayed to Resident 1's physician to obtain an order for another ST evaluation to ensure Reisdent 1 was evaluated by the expert (ST). ADM stated Resident 1 could be at risk for aspiration due to the resident's cognitive and medical condition like hemiplegia and hemiparesis if the staff are not providing the assistance or supervision that the resident needs. A review of the facility's policy and procedure titled, Aspiration Precaution, dated 4/1/2023, indicated residents at risk for aspiration may include but is not limited to the following conditions which include stroke, and the attending physician will be notified when a resident displays signs and symptoms of potential aspiration. The policy also indicated a speech therapist evaluation will be completed as indicated and ordered by the attending physician and update the resident's plan of care as indicated. 055818 Page 2 of 2