Royal Terrace Healthcare

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

personal hygiene. The MDS further indicated Resident 2 was dependent with upper/lower body dressing and putting on/taking off footwear.During an interview on 9/17/25 at 10:40 a.m. with RN Supervisor 1 (RN 1), RN 1 stated she completed a COC for Resident 1 due to his hypersexual behavior where he walked around in the hallways with his pants down and exposing himself to staff and residents. RN 1 stated she reported Resident 1's behavior to the previous Director of Nursing. RN1 stated she related inappropriate behavior to Resident 1's diagnosis of dementia and did not believe it was sexual abuse. During an interview

on 9/17/25 at 11:45 a.m. with Resident 2, Resident 2 stated Resident 1 took off his pants and underwear [in

the room] and played with his private parts. Resident 2 stated when Resident 1 was touching himself it made Resident 2 uncomfortable. Resident 2 stated, I was afraid of what could happen to me. I didn't sleep at all because I didn't feel safe in the room. Resident 2 stated he told his concerns to the nursing staff and all they told him was to use the call light to call them if something happened and then they would come right away. During an interview on 9/17/25 at 12:55 p.m. with RN 1, RN 1 stated Resident 2 did not report being uncomfortable in the room with Resident 1. RN 1 stated she could not remember who the other residents were that got exposed to Resident 1 in the hallways. RN 1 stated, It was reported to me that Resident 1 was walking out of his room with his pants down at his ankles. During a concurrent review of Resident 1's Transfer form, dated 8/19/25 and interview with RN Supervisor 2 (RN 2) on 9/17/25 at 4:35 p.m., RN 2 stated Resident 1 was confused, needed redirection, but continued inappropriate sexual behavior; that's why they transferred him. RN 2 was asked if Resident 2 was safe with Resident 1 who was displaying behavior such as masturbating in the open where other residents could see. RN 2 stated Not safe if Resident 2 is alone in the room with Resident 1. RN 2 stated based on the facility's abuse protocol the previous administrator should have been informed about the incident with Resident 1. During a review of

the facility's current Policy & Procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017,

the P&P indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies ( as defined by current regulations) and thoroughly investigated by facility management.

Findings of abuse investigations will also be reported.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8/19/25) and Change of Condition (dated 8/19/25) with RN 1 on 9/18/25 at 3:04 p.m., RN 1 acknowledged

she wrote the Progress note dated 8/19/25 at 2:22 p.m. RN 1 stated she only reported to the previous Director of Nursing (DON) about Resident 1's behavior, she did not report it to the previous administrator.

RN 1 stated she associated Resident 1's inappropriate sexual behavior with his dementia diagnosis and did not see it as sexual abuse. RN 1 stated Resident 1's history showed he had inappropriate sexual behavior prior to coming to the facility. RN 1 read her note again and then acknowledged that Resident 1 exposing and touching himself in the hallways where other residents were present is a form of sexual abuse and it should have been reported.During a review of the facility's current Policy & Procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017, the P&P indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Vocational Nurse 1 (LVN 1) on 9/17/25 at 12:34 p.m., LVN 1 stated, Resident 1 always had his hand in his pants touching himself. When I gave him medications, he was displaying that behavior and I told him to stop, then he would accept his medications after being told to stop that behavior. LVN 1 stated, Sexual abuse is reportable if a resident is in the hallways with his pants down and touching himself in front of other residents who feel uncomfortable with what is happening. LVN 1 stated, For sexual abuse, a change of condition should be initiated then the MD and family representative are notified. The police, Ombudsman, and CDPH are notified about the event. LVN 1 stated a care plan for sexual abuse or inappropriate sexual behavior should be initiated also.During a review of the facility's current Policy & Procedure (P&P) titled, Change in Resident's Condition or Status, revised February 2021, the P&P indicated Policy Interpretation and Implementation: The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self--limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan. The P&P further indicated, The nurse will record in the resident's medical

record information relative to changes in the resident's medical/mental condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI (Minimum Data Set Resident Assessment Instrument) Instruction Manual.

During a review of the facility's current Policy & Procedure (P&P) titled, Care Planning - Interdisciplinary Team, revised March 2022, the P&P indicated Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The IDT includes but is not limited to a) the resident's attending physician; b) a registered nurse with responsibility for the resident; c) a nursing assistant with responsibility for the resident; d) a member of the food and nutrition services staff; e) to the extent practicable, the resident and/or the resident's representative; and f) other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. The interdisciplinary team is responsible for the development of resident care plans.

Event ID:

Facility ID:

If continuation sheet