Royal Terrace Healthcare: Elopement Risk Failures - CA
That was the plan. Watch him. Check his belongings.
No formal elopement assessment had been completed for the resident, identified in inspection records only as Resident 1. The facility's own policy required one.
Federal inspectors cited Royal Terrace Healthcare following a complaint inspection on September 10, 2025, documenting that the facility failed to follow its written procedures for residents who pose an elopement risk. The violation was cited under F0689, which covers the obligation to protect residents from accidents and preventable harm. Inspectors assessed the level of harm as minimal or potential for actual harm.
The director of nursing, during the inspection, confirmed that Resident 1 would be considered an elopement risk based on the resident's own stated desire to leave. The DON's response was to issue a general instruction to staff: monitor the resident closely, and watch for signs he was preparing to go. There was no documented risk assessment. No formal safety plan tied to what Resident 1 had said.
Royal Terrace Healthcare's own elopement and wandering policy, reviewed by inspectors during the visit, states that a wander and elopement assessment will be completed on all residents upon admission. It further states the assessment is to be repeated quarterly, or sooner if a resident's condition changes.
A resident expressing a desire to leave the building is precisely the kind of change in condition that triggers that requirement. It did not trigger it here.
The gap between what a facility's written policy promises and what staff actually do is one of the most consistent findings in nursing home inspections. Policies get written, approved, filed. They describe a careful, systematic process. Then something happens, a resident says he wants to go home, and the response is a hallway conversation about watching his bags.
The DON's instruction was not nothing. Staff awareness matters. But awareness without documentation, without a structured assessment of how serious the risk is and what specific steps are needed to manage it, leaves a resident's safety dependent on whoever happens to be paying attention that shift.
Elopement from a nursing facility carries serious consequences. Residents who leave unsupervised, particularly those with cognitive impairment or physical vulnerability, face exposure to traffic, weather, disorientation, and falls. The inspection report does not describe what happened to Resident 1, whether he left the facility or was kept safe. It documents only that the structure meant to protect him was not in place.
The facility's policy existed. The DON knew the resident was a risk. The assessment did not happen.
Inspectors noted the violation affected a small number of residents. The citation does not describe any injury to Resident 1. What it describes is a system that was bypassed at the moment it was most needed, replaced by an informal instruction that left no record of what the risk was, how serious it was judged to be, or what anyone was specifically supposed to do about it.
Royal Terrace Healthcare is a licensed nursing facility in Duarte, in Los Angeles County. The September inspection was conducted in response to a complaint.
Resident 1 said he wanted to leave. The director of nursing told staff to watch him. Somewhere in that gap between a verbal instruction and a completed assessment, the process that was supposed to protect him simply did not occur.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Terrace Healthcare from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
ROYAL TERRACE HEALTHCARE in DUARTE, CA was cited for violations during a health inspection on September 10, 2025.
No formal elopement assessment had been completed for the resident, identified in inspection records only as Resident 1.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.