Health inspection·December 23, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of one sampled resident (Resident 1), who was assessed as self-responsible and capable of making decisions was accurately documented in the medical record. Resident 1's discharge to the facility was incorrectly recorded as leaving against medical advice (AMA- defined as those residents who chose to leave before the treating physician determined it was medically safe or appropriate), on 12/22/2025. Resident 1's records did not indicate the basis of the discharge, in accordance with the facility's policy and procedure (P&P) titled Transfer of Discharge Documentation and Transfer or Discharge, preparing a Resident for. This failure resulted in violating Resident 1's rights and was involuntarily discharged from the facility on 12/22/2025. Resident 1 had been reported missing on 12/20/2025 after failing to arrive for a scheduled dialysis appointment on 12/20/2025. On 12/31/2025, Resident 1 was found by a security guard from a local hotel and took Resident 1 back to the facility on the same date. The facility arranged for Resident 1 to be transferred to the general acute care hospital (GACH) on 12/31/2025 where resident 1 received hemodialysis treatments and readmitted back to the facility on 1/3/2026. Findings: During a review of Resident 1's admission Record (AR) , the AR indicated the facility originally admitted Resident 1 on 12/19/2024 with diagnoses that included end stage renal disease (kidneys have permanently lost nearly all of their ability to function), diabetes (high blood sugar), dementia and dependence on renal dialysis (a life-sustaining treatment that artificially filters waste products and excess fluid from the blood when the kidneys fail). During a review of Resident 1's History and Physical (H&P) dated 3/12/2025, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Order Summary Review, the report indicated the following physician orders: Dated 04/11/2025, the order indicated Resident 1 Dialysis scheduled every Tuesdays and Saturdays at 1:30 PM to 5:30 PM via a regular transportation. Dated 07/23/2025, the order indicated Resident 1 may go out on pass with a family member for therapeutic purposes, not to exceed 4 hours. Further review of the resident's records that included progress notes, care plans, IDT notes, did not indicate the reason why Resident 1's out on pass order was limited to 4 hours only and if the facility had discussed the plan/OOP order with a family member or emergency contact. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/09/2025, the MDS indicated Resident 1 was cognitively intact (alert, oriented, and able to think, remember and communicate clearly) with functional limitations that requires the use of walker for ambulation. During a review of Resident 1's progress note dated 12/20/2025 at 12:50 PM, the note indicated that facility staff witnessed Resident 1 getting into the transportation van to go to the dialysis center. During a review of Resident 1's progress note dated 12/20/2025 at 3:27 PM, the note indicated that the facility received a call from staff at the dialysis center on 12/20/2025 at 2:15 PM indicating that Resident 1 did not arrive for his dialysis treatment that day. The note Page 1 of 8 055899 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated that RN 1 called the transportation company and relayed that dialysis center staff reported Resident 1 had not arrived for his dialysis appointment. The note further indicated that the transportation company informed RN 1 that the driver had dropped off Resident 1 at the dialysis center on 12/20/2025, about an hour prior to the phone call. During a review of Resident 1's progress note dated 12/20/2025 at 11:20 PM, the note indicated that the staff from 3-11 PM shift reported Resident 1 did not return to the facility and staff were unable to contact the resident by phone. The note further indicated that the local police department was contacted at this time, and a missing person report was filed for Resident 1. During a review of Resident 1's progress notes dated 12/21/2025 at 8:12 AM, the note indicated Resident 1 was still missing and no updates from the police department. During a review of Resident 1's progress note titled Discharge Summary, dated 12/22/2025 at 2:55 PM, the record indicated that Resident 1 had been missing from the facility since 12/20/2025. The record indicated that the local police department and Resident 1's emergency contact were notified. The note also indicated that staff tried to reach out to Resident 1 but Resident 1 did not answer his cell phone. The note further indicated that Resident 1 was alert and oriented to person, place, time, and situation and was deemed to have left the facility against medical advice (AMA) as of 12/22/2025. During a review of Resident 1's GACH 1 records titled History of Present Illness dated 12/31/25 timed at 10:47 PM, the GACH record indicated Resident 1 was admitted to the GACH for missed hemodialysis treatments and received catch up hemodialysis at the GACH. The GACH record further indicated Resident 1 received 5 units of insulin intravenously (IV) and corrected hyperkalemia of 5.7 (normal levels at 3.6 to 5.2 millimoles per liter) upon arrival to the GACH. During a review of Resident 1's Progress notes dated 1/3/26, the notes indicated Resident 1 was readmitted back from a general acute care hospital (GACH) on 1/3/26 with diagnoses including ESRD, hyperkalemia, and cirrhosis of the liver. The notes indicated the local police department and the resident's second emergency contact was made aware. During a review of Resident 1's Progress notes, dated 1/4/26, the notes indicated the local police officer arrived at the facility to check on Resident 1. The note indicated Resident 1 informed the police officer that he went to a hotel through a bus during the times that he was missing. During an interview on 12/23/2025 at 10:10 AM with Social Worker (SW1) from the dialysis center, SW1 stated that Resident 1 was scheduled for hemodialysis twice weekly on Tuesdays and Saturdays. SW1 stated the resident's next scheduled appointment was on 12/20/2025, but Resident 1 did not arrive to his dialysis treatment. SW1 stated the transportation van driver reported that Resident 1 was dropped off at the dialysis center on 12/20/2025.At 2:15 pm SW 1 stated the Dialysis center called to notify the facility that Resident 1 did not arrive to the dialysis appointment. SW 1 stated the facility did not know Resident 1 was missing. During an interview on 12/23/2025 at 11:42 AM with Registered Nurse (RN) 1, RN1 stated that Resident 1 had been missing since Saturday, 12/20/2025. RN1 stated the resident was picked up from the facility by transportation, and approximately one hour later, the dialysis center called to inquire about the resident's whereabouts. RN1 stated she informed the dialysis center that Resident 1 had been transported to their location. RN1 stated the transportation company returned at the scheduled time to pick up the resident, but the resident was not found. RN1 stated the police were not notified until the end of the shift, as staff hoped the resident would return for pickup. RN1 further stated that Resident 1 tends to be sneaky and has a history of leaving without notice. During an interview on 12/23/2025 at 12 PM with the Director of Nursing (DON), the DON stated that Resident 1 was discharged against medical advice (AMA) from the facility as of 12/22/2025, noting that Resident 1 left voluntarily, had decision-making capacity, and was not considered an elopement risk. The DON stated that the 3 to11 PM shift licensed nurse called the police and 055899 Page 2 of 8 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attempted to contact Resident 1's Emergency Contact #2 but was unable to reach him. The DON further stated that Emergency Contact #1 did not have a working phone number either. The DON stated that she had never been able to reach any family members since Resident 1's admission to the facility. 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 a concurrent interview and record review on 12/23/2025 at 1:40 PM with the Director of Nursing (DON), Resident 1's medical records were reviewed. The DON stated that no care plan, interdisciplinary team documentation, or physician discharge order could be found in the resident's medical record. Additionally, the DON stated there was no documentation indicating that the resident had been informed of, participated in, or was aware of any planned discharge. 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 stated the resident was discharged AMA because he was aware of the requirement to return within four hours. MD1 further explained that if the resident exceeded the allotted time frame, the facility would attempt to contact him, and if no response was received, the resident would be discharged AMA. 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 review. 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(continued on next page) 055899 Page 3 of 8 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0627 holding policies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055899 Page 4 of 8 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement resident centered care plan interventions and interdisciplinary team involvement for one of two sampled residents (Resident 1), who had a behavior and history of leaving the facility without permission and failing to return from out on pass, in accordance with the physician's order. The facility did not initiate behavioral interventions, or document strategies to address repeated non-compliance and unsafe behaviors of leaving facility without permission. Resident 1 left the facility without permission on 12/16/25 with no documented evidence of Resident 1's status when he came back to the facility. Resident 1 left the facility after being dropped off to the Dialysis center on 12/20/25 and did not come back to the facility until 12/31/25. Resident 1 was transferred to a general acute care hospital (GACH) for evaluation on 12/31/25 and readmitted back to the facility on 1/3/26 and received dialysis treatments at the GACH. These deficient practices had the potential to result in increased risk of elopement, medical emergencies while unsupervised, delayed medically necessary treatments and appointments having the potential to compromise the resident's safety, health, and wellbeing. Cross referenced to F627Findings: During a review of Resident 1's admission Record (AR) , the AR indicated the facility originally admitted Resident 1 on 12/19/2024 with diagnoses that included end stage renal disease (kidneys have permanently lost nearly all of their ability to function), diabetes (high blood sugar), dementia, and dependence on renal dialysis (a life-sustaining treatment that artificially filters waste products and excess fluid from the blood when the kidneys fail). During a review of Resident 1's History and Physical (H&P) dated 3/12/2025, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Order Summary Review, the report indicated the following physician orders: Dated 04/11/2025, the order indicated Resident 1 Dialysis scheduled every Tuesdays and Saturdays at 1:30 PM to 5:30 PM via a regular transportation. Dated 07/23/2025, the order indicated Resident 1 may go out on pass with a family member for therapeutic purposes, not to exceed 4 hours. Further review of the resident's records that included progress notes, care plans, IDT notes, did not indicate the reason why Resident 1's out on pass order was limited to 4 hours only and if the facility had discussed the plan/OOP order with a family member or emergency contact. During a review of Resident 1's physician order dated 11/18/25 indicating for Resident 1 to have a psychiatric (psych) evaluation. The resident's records did not indicate the reason for the psych order. Further review of Resident 1's records for November and December 2025 did not indicate documented evidence that the psych eval order was initiated or scheduled after the order was placed on 11/18/25. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/09/2025, the MDS indicated Resident 1 was cognitively intact (alert, oriented, and able to think, remember and communicate clearly) with functional limitations that requires the use of walker for ambulation. During a review of Resident 1's progress notes dated 12/16/2025 documented at 3:51 PM, the note indicated Resident 1 missed dialysis at this day, 12/16/2025 and dialysis treatment was rescheduled for 12/18/2025. The note did not indicate the reason why Resident 1 missed his dialysis appointment and the resident's whereabouts. The note did not indicate the physician was made aware. The progress notes did not indicate the date, time, and status of Resident 1 when he came back to the facility after leaving the facility without permission on 12/16/2025. During a review of Resident 1's progress note dated 12/20/2025 at 12:50 PM, the note indicated that facility staff witnessed Resident 1 getting into the transportation van to go to the dialysis center. During a review of Resident 1's progress note dated 12/20/2025 at 3:27 PM, the note indicated that the facility received a call 055899 Page 5 of 8 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from staff at the dialysis center on 12/20/2025 at 2:15 PM indicating that Resident 1 did not arrive for his dialysis treatment that day. The note indicated that RN 1 called the transportation company and relayed that dialysis center staff reported Resident 1 had not arrived for his dialysis appointment. The note further indicated that the transportation company informed RN 1 that the driver had dropped off Resident 1 at the dialysis center on 12/20/2025, about an hour prior to the phone call. The note also indicated that the driver recalled Resident 1 had asked to be picked up from the dialysis center at 4:45 PM. During a review of Resident 1's progress note dated 12/20/2025 at 11:20 PM, the note indicated that the staff from 3-11 PM shift reported Resident 1 did not return to the facility and staff were unable to contact the resident by phone. The note further indicated that the local police department was contacted at this time, and a missing person report was filed for Resident 1. During a review of Resident 1's progress notes dated 12/21/2025 at 8:12 AM, the note indicated Resident 1 was still missing and no updates from the police department. During a review of Resident 1's progress note titled Discharge Summary, dated 12/22/2025 at 2:55 PM, the record indicated that Resident 1 had been missing from the facility since 12/20/2025. The record indicated that the local police department and Resident 1's emergency contact were notified. The note also indicated that staff tried to reach out to Resident 1 but Resident 1 did not answer his cell phone. The note further indicated that Resident 1 was alert and oriented to person, place, time, and situation and was deemed to have left the facility against medical advice (AMA - the patient chose to leave before the treating physician believed it was medically safe or appropriate) as of 12/22/2025. During a review of Resident 1's Progress notes dated 12/23/2025 at 9: 23 AM, the note indicated resident is still out of the facility. During a review of Resident 1's GACH 1 records titled History of Present Illness dated 12/31/25 timed at 10:47 PM, the GACH record indicated Resident 1 was admitted to the GACH for missed hemodialysis treatments and received catch up hemodialysis at the GACH. The GACH record further indicated Resident 1 received 5 units of insulin intravenously (IV) and corrected hyperkalemia of 5.7 (normal levels at 3.6 to 5.2 millimoles per liter) upon arrival to the GACH. During a review of Resident 1's Progress notes dated 1/3/26, the notes indicated Resident 1 was readmitted back from a general acute care hospital (GACH) on 1/3/26 with diagnoses including ESRD, hyperkalemia, and cirrhosis of the liver. The notes indicated the local police department and the resident's second emergency contact was made aware. During a review of Resident 1's Progress notes, dated 1/4/26, the notes indicated the local police officer arrived at the facility to check on Resident 1. The note indicated Resident 1 informed the police officer that he went to a hotel through a bus during the times that he was missing. During an interview on 12/23/2025 at 10:10 AM with Social Worker (SW1) from the dialysis center, SW1 stated that Resident 1 was scheduled for hemodialysis twice weekly on Tuesdays and Saturdays. SW1 stated the facility rescheduled the resident's regular Tuesday dialysis appointment to Thursday, 12/18/2025, because the resident walked out of the facility on 12/16/2025. SW1 stated Resident 1 attended the rescheduled dialysis appointment on 12/18/2025. SW1 further stated the resident's next scheduled appointment was on 12/20/2025, but Resident 1 did not arrive. SW1 stated the transportation van driver reported that Resident 1 was dropped off at the dialysis center on 12/20/2025, but Resident 1 did not enter the dialysis center. At 2:15pm SW 1 stated they called to notify the facility that Resident 1 did not arrive to the dialysis appointment. SW 1 stated the facility did not know Resident 1 was missing. During an interview on 12/23/2025 at 11:42 AM with Registered Nurse (RN) 1, RN1 stated that Resident 1 had been missing since Saturday, 12/20/2025. RN1 stated the resident was picked up from the facility by transportation, and approximately one hour later, the dialysis center called to inquire about the resident's whereabouts. RN1 stated she informed the dialysis center 055899 Page 6 of 8 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident 1 had been transported to their location. RN1 stated the transportation company returned at the scheduled time to pick up the resident, but the resident was not found. RN1 stated the police were not notified until the end of the shift, as staff hoped the resident would return for pickup. RN1 further stated that Resident 1 tends to be sneaky and has a history of leaving without notice. RN 1 recalled that on Tuesday, 12/16/2025, the resident left the facility without permission and missed the dialysis appointment. RN 1 stated she had to reschedule Resident 1's missed dialysis appointment that day (12/16/2025). RN 1 could not find documentation what time Resident 1 came back to the facility on [DATE] after leaving the facility without permission. During an interview on 12/23/2025 at 12 PM with the Director of Nursing (DON), the DON stated that Resident 1 had been dropped off by transportation for a procedure at the dialysis center on 12/20/2025. The DON stated that Resident 1 told the driver to return and pick him up at 4:45 PM. The DON stated the dialysis center later informed the facility that Resident 1 never checked in for the appointment. The DON stated that Resident 1 was discharged against medical advice (AMA) from the facility as of 12/22/2025, noting that Resident 1 left voluntarily, had decision-making capacity, and was not considered an elopement risk. The DON stated that the 3 to11 PM shift licensed nurse called the police and attempted to contact Resident 1's Emergency Contact #2 but was unable to reach him. The DON further stated that Emergency Contact #1 did not have a working phone number either. The DON stated that she had never been able to reach any family members since Resident 1's admission to the facility. Further review of Resident 1's records indicated no documented evidence of the facility's IDT involvement with Resident 1's family members or significant other as indicated in the resident's face sheet and in accordance with the physician's order dated 7/23/25, that Resident 1 may only go out on pass for four hours for therapeutic purposes, with a family member. 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 055899 Page 7 of 8 055899 12/23/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0740 implementation of the care plan. Interventions will be individualized and part of an overall care environment . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055899 Page 8 of 8