Royal Terrace Healthcare
ROYAL TERRACE HEALTHCARE in DUARTE, CA — inspection on September 19, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Terrace Healthcare
1340 Highland Ave.
Duarte, CA 91010
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Terrace Healthcare
1340 Highland Ave.
Duarte, CA 91010
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.