Royal Terrace Healthcare
Duarte, California · CCN 055541
35 surveys since 2010, 8 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 189
- Surveys
- 35
- Harm or worse
- 8
- Immediate jeopardy
- 4
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 58
- Ownership
- For profit - Limited Liability company
- Chain
- SERRANO GROUP
- County
- Los Angeles
- Medicare-certified since
- 1996
CMS ratings
- Overall
- 3
- Health inspection
- 2
- Staffing
- 3
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 252 for-profit facilities with fewer than 66 beds in California.
Last survey on record
Jun 26, 2026
136 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.73 | 4.36 |
| Registered-nurse hours per resident day | 0.53 | — |
| Annual nurse turnover | 55.6% | 36.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2050.0% | E1742.5% | F12.5% |
| No harm, potential for minimal | A— | B25.0% | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6565×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5582×
Reasonably accommodate the needs and preferences of each resident.
- F5782×
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.
In the surveyor’s words
From the most serious findings on record at Royal Terrace Healthcare, in the surveyor’s own words.
- Immediate jeopardy, widespreadF812Dec 10, 2021
Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition by not ensuring food was stored, prepared, and served in accordance with professional standards of food service safety. The facility did not: 1. Eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen and the janitor's closet. 2. […]
- Immediate jeopardy, widespreadF880Dec 10, 2021
Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist [IP] Nurse, to provide a safe and sanitary environment by having: 1. Cockroaches (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen. 2. Harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors and on different surfaces in the kitchen. […]
- Immediate jeopardy, widespreadF925Dec 10, 2021
Based on observation, interview, and record review, the facility failed to remain free of pests by not having an effective pest control. For 42 of 42 (Residents 1-42) residents in the facility, who received food, fluids, and used tableware from the kitchen, the facility failed to: 1. Eradicate (destroy/kill) cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls, floors, and different surfaces in the kitchen. […]
- No harm, potential for more than minimal, widespreadF727Dec 23, 2025
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. […]
- No harm, potential for more than minimal, patternF641May 22, 2026
Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 23 and 36) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 23's diagnosis of depression (feeling of deep sadness that made a resident lose interest in things they once enjoyed) was coded in MDS assessment dated [DATE]. b. Ensure Resident 36's use of antipsychotic medication was coded accurately in the MDS assessment dated [DATE]. […]
Read 28 findings in full →The most serious and the most recent: 28 of 189 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 26, 2026Complaint2 findings
- May 22, 2026Standard8 findings
- Dec 23, 2025Complaint1 finding
- Oct 28, 2025Complaint1 finding
- Sep 19, 2025Complaint3 findings
- Sep 10, 2025Complaint1 finding
- Jul 31, 2025Complaint1 finding
- May 30, 2025Standard10 findings
Show the 27 earlier surveys
- Jun 16, 2024Standard8 findings
- Apr 30, 2024Complaint5 findings
- Jun 30, 2022Complaint1 finding
- Jun 17, 2022Complaint1 finding
- May 26, 2022Complaint1 finding
- May 16, 2022Complaint1 finding
- Jan 21, 2022Standard and complaint10 findings
- Dec 10, 2021Complaint3 findings · 3 harm
- Dec 9, 2021Complaint2 findings
- May 27, 2020Complaint1 finding
- May 12, 2020Complaint3 findings
- May 6, 2020Complaint1 finding
- Apr 22, 2020Complaint1 finding
- Apr 15, 2020Complaint1 finding
- Apr 7, 2020Complaint1 finding
- Dec 5, 2019Standard9 findings
- Dec 2, 2018Standard12 findings
- Jun 19, 2018Complaint1 finding
- Jun 15, 2018Complaint1 finding · 1 harm
- Apr 26, 2018Complaint1 finding
- Nov 22, 2017Standard18 findings
- Feb 10, 2017Standard18 findings
- Jan 8, 2016Standard and complaint15 findings · 2 harm
- Oct 17, 2014Standard7 findings
- Jun 22, 2013—14 findings
- Mar 11, 2012Standard18 findings · 2 harm
- Dec 18, 2010—8 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction