Royal Gardens Healthcare

In the surveyor’s words

From the most serious findings on record at Royal Gardens Healthcare, in the surveyor’s own words.

• Actual harm, patternF925Aug 23, 2022

  Based on observation, interview and record review the facility failed to maintain an effective pest control program in the facility and failed to prevent mosquito bites affecting three out of three sampled residents (Resident 1, Resident 2, and Resident 3) in accordance with facility ' s policy and procedure. These deficient practices had the potential to result to serious illness and has the potential to affect all 33 residents if the mosquitoes were able to enter and bite the residents in the facility. […]

• No harm, potential for more than minimal, patternF921Aug 27, 2026

  Based on observation, interview, and record review, the facility failed to maintain and provide a safe and comfortable environment including maintain temperature within 71-81-degree Fahrenheit when the west wing air-conditioning unit (AC Unit #A) became nonfunctional on 8/26/2026 at 5 AM. This deficient practice not only exposed residents, visitors and staff to excessive room temperatures but also had the potential to cause residents to experience heat-related illnesses, such as heat cramps (painful muscle cramps and spasms), heat exhaustion (more severe than heat cramps and results from a loss of water and salt in the body), and heat stroke (the most severe form of heat illness, occurs when the body's heat-regulating system is overwhelmed by excessive heat. […]

• No harm, potential for more than minimal, patternF558Aug 21, 2026

  Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs by failing to ensure that the call light device (one of the major communication technologies that links nursing home staff to the needs of residents) was within reach and answered timely for two (2) of three (3) sampled residents (Residents 1 and 3). This failure had the potential to cause a delay in care for Residents 1 and 3 and prevent the residents from receiving the necessary care and services, which could lead to illness or serious injury.Findings: 1. […]

• No harm, potential for more than minimal, patternF684Apr 16, 2026

  Based on interview and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two (2) of 2 sampled residents (Resident 4 and 7) by failing to:Continue and provide wound care treatment per physician (MD) orders for Resident 4.Ensure Resident 7 was seen by a pain specialist (a doctor who has specialized fellowship training in evaluating, diagnosing, and treating acute, chronic, or cancer-related pain) from 1/16/2026 to 4/16/2026 in accordance with the MD order. […]

• No harm, potential for more than minimal, patternF880Apr 16, 2026

  Based on observation, interview and record review, the facility failed to follow their infection control policy and procedure for two (2) of three (3) sampled residents (Residents 1 and 3) by:1. Not ensuring Registered Nurse 1 (RN 1) changed gloves and performed hand hygiene (washing hands with either an alcohol based hand sanitizer or washing hands) when going from dirty to clean task during wound care treatment for Resident 3 and did not perform hand hygiene after doffing (taking off) personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) after leaving the Resident 3's room.2. […]