Facility Watch Inspection records for every certified US nursing home

Royal Terrace Healthcare

1340 Highland Ave.
Duarte, CA 91010
(626) 256-4654

CCN
055541
Certified beds
58
Ownership
For profit - Limited Liability company
Chain
Serrano Group

Nurse staffing

4.18
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.46 hours per resident per day

Nursing staff turnover: 49% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected December 23, 2025

1 citation · from a complaint investigation · Health
F
F0727 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected January 16, 2026

Inspected October 28, 2025

1 citation · from a complaint investigation · Health
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected November 21, 2025

Inspected September 19, 2025

3 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected September 28, 2025
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected September 28, 2025
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected November 19, 2025

Inspected September 10, 2025

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected September 25, 2025

Inspected July 31, 2025

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected August 20, 2025

Inspected May 30, 2025

10 citations · Health
B
F0912 No actual harm with potential for minimal harm · Pattern

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Waiver has been granted · corrected May 30, 2025
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected June 19, 2025
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected June 20, 2025
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected June 19, 2025
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected June 9, 2025
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected June 19, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected May 30, 2025
E
F0578 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Deficient, Provider has date of correction · corrected June 19, 2025
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected June 19, 2025

Inspected June 16, 2024

8 citations · Health
B
F0912 No actual harm with potential for minimal harm · Pattern

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Waiver has been granted · corrected July 1, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 3, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected July 5, 2024
D
F0810 No actual harm with potential for more than minimal harm · Isolated

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Deficient, Provider has date of correction · corrected July 8, 2024
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected July 1, 2024
E
F0578 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Deficient, Provider has date of correction · corrected July 1, 2024
E
F0694 No actual harm with potential for more than minimal harm · Pattern

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Deficient, Provider has date of correction · corrected July 8, 2024
E
F0695 No actual harm with potential for more than minimal harm · Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected July 3, 2024

Inspected April 30, 2024

5 citations · from a complaint investigation · Health
E
F0558 No actual harm with potential for more than minimal harm · Pattern

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected June 6, 2024
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected June 6, 2024
E
F0688 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Deficient, Provider has date of correction · corrected June 6, 2024
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected June 6, 2024
E
F0726 No actual harm with potential for more than minimal harm · Pattern

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Deficient, Provider has date of correction · corrected May 23, 2024

Inspected January 21, 2022

10 citations · Health
B
F0912 No actual harm with potential for minimal harm · Pattern

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Deficient, Provider has date of correction · corrected March 1, 2022
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected March 1, 2022
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected March 1, 2022
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected March 1, 2022
D
F0881 No actual harm with potential for more than minimal harm · Isolated

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected March 1, 2022
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 1, 2022
E
F0698 No actual harm with potential for more than minimal harm · Pattern

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected March 1, 2022
E
F0867 No actual harm with potential for more than minimal harm · Pattern

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected March 1, 2022
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected March 1, 2022
E
F0921 No actual harm with potential for more than minimal harm · Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected March 1, 2022

Ownership transfers

EffectiveSellerBuyer
01/01/2016Royal Terrace LLCRoyal Terrace Healthcare LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.