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, Page 1 of 2 055541 055541 12/23/2025 Royal Terrace Healthcare 1340 Highland Ave. Duarte, CA 91010

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many supports best practices, and participates in revising policies and procedures as needed. During a review of the facility's P&P titled, Job Description for RN, updated 11/1/2024, the P&P indicated that the registered nurses need report to DON. During a review of the facility's P&P titled, staffing, revised 10/2017, the P&P indicated that the facility must provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 055541 Page 2 of 2