Health inspection·July 31, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 was requesting to be sent to the hospital. RR 1 stated RR 1 called later at 10:30 PM and spoke to Registered Nurse (RN) 1. RR 1 stated RN 1 informed RR 1 that RN 1 was waiting for the doctor to determine which hospital the facility would send Resident 1 to on 7/21/2025 at 2 AM. RR 1 stated RR 1 spoke to another unidentified nurse during the night of 7/21/2025 and was informed the facility would notify RR 1 when the doctor called back. RR 1 stated RR 1 called the facility early in the morning of 7/22/2025 and spoke to RN 2 about Resident 1's complaint of chest pain and asked about the transfer to the hospital. RR 1 stated RN 2 called RR 1 back in 1/2 hour and informed RR 1 that Resident 1 would be transferred to the hospital at 10:30 AM on 7/22/2025.During an interview on 7/30/2025 at 10:55 AM with Resident 1, Resident 1 stated Resident 1 started to feel ill with a cough on 7/20/2025. Resident 1 stated Resident 1 informed the staff (unidentified) the evening of 7/20/2025 that Resident 1 had a cough. Resident 1 stated Resident 1 informed the nurse (unidentified) on 7/21/2025 at around 2 AM that Resident 1 was short of breath (SOB) and that Resident 1's chest hurt whenever Resident 1 took a breath. Resident 1 stated the facility staff (unidentified) just wanted to give Resident 1 medicine for the cough but Resident 1 informed the facility staff (unidentified) Resident 1 needed to go to the hospital. Resident 1 stated Resident 1 felt upset because the facility waited over 24 hours before listening to Resident 1 and before sending Resident 1 to the hospital. Resident 1 stated Resident 1 knew something was wrong. Resident 1 stated Resident 1 knew Resident 1's body. Resident 1 stated Resident 1 spent 7 days at GACH 1 with pneumonia in both lungs.During a concurrent interview and record review on 7/30/2025 at 12:10 PM with RN 2, Resident 1's Change in Condition Evaluation (CIC), dated 7/22/2025 and timed 8:14 AM, was reviewed. The CIC indicated Resident 1 had, Elevated BP (blood pressure), cough and chest tightness. The CIC indicated Resident 1's doctor ordered for Resident 1 to be sent to GACH 1. RN 2 stated Resident 1 had been pushing to go to the hospital for the last two days.During an interview on 7/30/2025 at 12:51 PM with the SSD, the SSD stated RR 1 called the SSD on 7/21/2025 during the day (time unknown) and wanted to speak to the SSD about Resident 1 being transferred to a hospital. The SSD stated RR 1 informed the SSD Resident 1 had a cough and was having pain. The SSD stated RR 1 wanted Resident 1 to be transferred to the hospital. The SSD stated the SSD directed RR 1 to talk to the nursing staff (in general).During an interview on 7/31/2025 at 10:53 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 complained of having back pain and requested to go to the hospital on 7/20/2025 during the evening time (exact time unknown). LVN 1 stated LVN 1 texted Resident 1's doctor but that the doctor did not reply. LVN 1 stated LVN 1 did not try to call the doctor when the doctor did not respond to the text message.During an interview on 7/31/2025 at 2:24 PM with RN 3, RN 3 stated RN 3 was the supervisor on the 3-11 shift on 7/20/2025. RN 3 stated RN 3 was notified by LVN 1 that Resident 1 wanted to go to the hospital. RN 3 stated Resident 1 told RN 3 that Resident 1 was in pain and wanted to go to the hospital. RN 3 stated Resident 1 claimed Resident 1 did not feel good. RN 3 stated LVN 1 notified Resident 1's doctor. RN 3 stated RN 3 was under the impression LVN 1 spoke to Resident 1's doctor about Resident 1's complaint of pain and wanting to be transferred to a hospital. RN 3 stated LVN 1 should have spoken to Resident 1's doctor and completed a CIC in Resident 1's medical record.During a concurrent interview and record review on 7/31/2025 at 2:38 PM with the DON, the facility's 24-hour communication log, undated, was reviewed. The 24-hour communication log indicated RN 1 made an entry regarding Resident 1on 7/21/2025 at 4:39 PM which indicated, Paged (Resident 1's doctor) regarding resident (Resident 1) and (RR 1) requesting to be transferred to (GACH 1) d/t uncontrollable pain. Paged MD twice on our shift. Awaiting for response. The DON confirmed Resident 1's medical record did not contain documentation regarding Resident 1's complaints of pain and requests to go to the hospital until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055541 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055541 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 7/22/2025. The DON stated RN 1 should have filled out a CIC on 7/21/2025 when Resident 1 had uncontrolled pain. The DON stated the DON was not made aware of Resident 1's complaints of pain or request to be transferred to the hospital until 7/21/2025 while the DON was driving home in the evening. The DON stated the DON instructed the facility staff (unidentified) to call Resident 1's doctor. The DON stated the facility staff should have called the DON if they were unable to reach Resident 1's doctor. The DON confirmed the facility staff did not get a hold of Resident 1's doctor until 7/22/2205 at 8:14 AM.During a review of the P&P titled, Changes in Resident Condition, undated, the P&P indicated, A facility must immediately. consult with the resident's physician.when there is: .A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life - threatening conditions or clinical). The P&P indicated, Document in the resident's medical record: Date and time of change of condition - Who (physician/family member/responsible party) was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided, document the time emergency personnel arrived and took over the care of the resident, if applicable, and update the care plan as needed. Event ID: Facility ID: 055541 If continuation sheet Page 3 of 3