Health inspection·October 28, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some follow-up interview on 10/27/2025 at 11:41 AM with Resident 2, Resident 2 stated Resident 2 had fallen multiple times at the facility. Resident 2 stated Resident 2 gets dizzy due to chemotherapy (a drug-based medical treatment that uses powerful chemicals to kill or slow the growth of cancer cells). Resident 2 stated Resident 2 was not supposed to walk by herself to the bathroom. Resident 2 stated Resident 2 had walked by herself earlier (when surveyor observed) without assistance from staff (in general) because staff did not always come right away when Resident 2 needed to use the toilet. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 1/22/2025 and readmitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system, metabolic encephalopathy (brain disease that alters brain function or structure), and seizures (a sudden, uncontrolled electrical disturbance in the brain). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was severely impaired in cognitive skills. The MDS indicated Resident 3 required supervision or touching assistance from staff for personal hygiene, bathing and dressing. The MDS indicated Resident 3 required supervision or touching assistance from staff for walking. During a review of Resident 3's General Acute Care Hospital 1 (GACH 1) Emergency Trauma Documentation (ETD) dated 5/31/2025, the ETD indicated Resident 3 presented to GACH 1 Emergency department (ED) on 5/31/2025 with chief complaint of a fall. The ETD indicated Resident 3 hit Resident 3's head when Resident 3 fell in the facility. The ETD indicated Resident 3 had a 3-centimeter (cm-unit of measurement) scalp laceration. The ETD indicated the physician repaired Resident 3's laceration with three staples (specialized staples that are used instead of sutures to mend skin wounds). During a review of Resident 3's GACH 2 ED Provider Note (ED Note), dated 8/4/2025, the ED Note indicated Resident 3 presented to GACH 2 ED on 8/4/2025 with a 4 cm laceration to the head due to an unwitnessed fall at the facility. The ED Note did not indicate any treatment for Resident 3's laceration. During a concurrent interview and record review on 10/27/2025 at 2:20 PM with the Director of Nursing (DON), Resident 3's Change in Condition Evaluation (CIC) dated 5/31/2025, 8/4/2025, and 10/4/2025 were reviewed. The DON stated Resident 3 had fallen at the facility on five separate occasions since being admitted to the facility. The DON stated Resident 3 had fallen three times, (5/31/2025, 8/4/2025, and 10/4/2025) since the facility's last recertification survey. The CIC dated 5/31/2025 indicated on 5/31/2025 at 1:20 PM, Resident 3 was found on the floor lying on the right side. The CIC indicated Resident 3 had a right head hematoma (bruising) and a laceration measuring around 3 cm. long. The CIC indicated Resident 3's physician instructed the facility to send Resident 3 via 911 (emergency response) to a General Acute Care Hospital (GACH) due to unwitnessed fall and to treat Resident 3's hematoma and laceration on Resident 3's head. The CIC indicated 911 was called and that emergency medical services (EMS) took Resident 3 to GACH 1. The CIC dated 8/4/2025 indicated on 8/4/2025 at 1:00 PM, Resident 3 was observed on the floor face down, and had a 5 cm long laceration on the forehead with bleeding. Resident 3 was transferred to (GACH 2) via 911 for further evaluation. The CIC dated 10/4/2025 indicated on 10/4/2025 at 1:20 PM, Resident 3 had an unwitnessed fall and was discovered on the floor. The CIC indicated, Resident 3 verbalized feeling dizzy and fell. The CIC indicated Resident 3's physician instructed the facility to send Resident 3 to GACH 3 for further evaluation. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's Nursing-Fall Risk Evaluation (FRE) dated 5/22/2025 and 10/4/2025 were reviewed. The DON stated the FRE dated 5/22/2025 inaccurately indicated Resident 3 had no falls in the last 90 days. The FRE dated 10/4/2025 inaccurately indicated Resident 3 was at low risk of falling. The DON stated the FRE dated 5/22/2025 incorrectly indicated Resident 3 was at low risk of falling instead of accurately indicating Resident 3 was at high risk of falling again. The DON stated an FRE was (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 10/28/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete required after each fall to help identify risks of falls prior to the resident falling again. The DON stated if an FRE is completed inaccurately, then residents had the potential to fall again. The DON also stated an FRE was not completed after Resident 3 fell on 5/31/2025. c. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's Progress Notes (PN) dated 10/27/2025 was reviewed. The PN indicated the IDT fall review committee met following Resident 3's falls on 5/31/2025, 8/4/2025 and 10/4/2025. The DON stated the IDT did not conduct a thorough root cause analysis for Resident 3 for each fall. The DON stated the IDT did not focus on Resident 3's diagnoses as being a contributing factor to Resident 3's repeated falls. The DON stated the IDT did not change interventions to prevent Resident 3 from falling but still expected the current interventions to prevent Resident 3 from falling again. The DON stated if the IDT did not conduct a thorough root cause analysis, Resident 3 would likely fall again. During a concurrent interview and record review on 10/28/2025 at 9:49 AM with the DON, Resident 3's undated Care Plan Report (CPR) was reviewed. The CPR indicated the facility failed to initiate or update Resident 3's care plan to address Resident 3's risk of falling again, following Resident 3's falls on 5/31/2025, 8/4/2025, and 10/4/2025. The DON stated the IDT did not review Resident 3's care plan following the falls. The DON stated if a resident (in general) had repeated falls then interventions used to prevent the falls must be changed since the current interventions were not working to prevent the falls. The DON stated if resident's care plan was not updated following a fall, the resident would be more likely to fall again. During a review of the facility's policy and procedure (P&P) titled, Fall Management & Prevention Policy, undated, the P&P indicated, the purpose of the fall management and prevention policy was, To minimize the risk of patient/resident falls and fall-related injuries by implementing assessment, prevention, and management strategies . The P&P indicated the responsibility of the facility's Clinical and Nursing staff (in general) was to: Conduct fall risk assessment on admission, transfer, after a fall, or when there is a significant change in condition. Develop and implement individualized fall prevention plans. Document interventions and patient/resident responses in the care record. Educate patients/residents and families on fall risks, prevention measures and safe mobility. Report all falls and near-falls immediately according to facility incident reporting procedures.The P&P indicated the responsibility of all staff was to . Maintain a safe physical environment: clear walkways, adequate lighting, safe flooring, proper use of equipment and assistive device. The P&P indicated Post Fall (after a resident falls at the facility) Management included: . Update the individual's care plan and risk status if needed. Convene a multidisciplinary fall review committee (e.g., nursing, PT/OT, risk management, quality/safety) to analyze:- The event's chain of events and contributing factors- Whether existing interventions were in place and effective- Recommend and implement corrective actions (e.g., change in intervention plan, staff education, environment modification) . Event ID: Facility ID: 055541 If continuation sheet Page 3 of 3