Health inspection·December 23, 2025

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview and record review, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis (working 40 or more hours a week) from 12/9/2025 to 12/23/2025 for 52 of 52 residents (census) in the facility.This deficient practice had the potential to impact the quality of care and outcomes that all residents experience in the facility.Findings: During an observation on 12/22/2025 from 8:05 AM to 5 PM and on 12/23/2025 from 8:02 am to 5 pm, there was no designated RN who served as the DON on a full-time basis in the facility. There were 52 residents in the facility on 12/22/2025 and on 12/23/2025. During a phone interview on 12/23/2025 at 9:08 AM with the former DON (FDON), the FDON stated FDON quit the facility in the first week of December 2025. The FDON could not recall the exact date of when the FDON quit the facility. During an interview on 12/23/2025 at 3:48 PM with the Administrator, the Administrator stated that the facility had not designated a specific RN to serve as a full-time DON for the facility since 12/9/2025. The Administrator stated Registered Nurse Consultant (RNC) 1, RNC 2, RN 1, RN 3 and RN 4 were currently the designated DON for the facility since 12/9/2025. During an interview on 12/23/2025 at 3:52 PM with RNC 1, RNC 1 stated that RNC 1 visited the facility 8 to 16 hours per week to provide oversight (having responsibility for supervision and management of nursing services) along with RNC 2. RNC 1 stated RNC 1 was not the designated DON for the facility because RNC 1 had only been an RN for three (3) months. RNC 1 stated the RNs and licensed vocational nurses (LVNs) who worked on the floor (provided direct resident care) in the facility were the designated DON when RNC 1 and RNC 2 were not in the facility. RNC 1 stated that the facility currently did not have a full-time DON since 12/9/2025. During a phone interview on 12/23/2025 at 4 PM with RNC 2, RNC 2 stated that RNC 2 was the designated DON for the facility since 12/9/2025 and visited the facility 8 to 16 hours per week. RNC 2 stated RNC 2 was available by phone 24 hours a day. During an interview on 12/23/2025 at 4:26 PM with RN 1, RN 1 stated RN 1 was not the designated DON for the facility and RNC 2 was the designated DON since 12/9/2025 and visited the facility 16 to 24 hours per week. RN1 stated RN 1 worked as a full-time RN in the facility on the day shift from 7 AM to 3:30 PM. During an interview on 12/23/2025 at 4:50PM with the Administrator, the Administrator stated that the facility should have designated an RN to serve as a DON on a full-time basis for the facility since 12/9/2025. During a review of the facility's Policy and Procedure (P&P) titled, Director of Nursing Services, revised 8/2022, the P&P indicated the DON had to be a registered nurse (RN), licensed by this state, had experience in nursing service administration, rehabilitative and geriatric nursing, and be employed as full-time (40 hours per week). During a review of the facility's P&P titled, Job Description for DON, updated 11/1/2024, the P&P indicated, The Director of Nursing (DON) is responsible for overseeing the administration of nursing services, ensuring compliance with Federal, State, and Local standards, guidelines, and regulations, as well as company policies and procedures. The P&P indicated, The DON leads the nursing team to deliver the highest quality of care, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055541 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 12/23/2025 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)