Royal Terrace Healthcare
1340 Highland Ave. · Duarte, CA · 91010 · 6262564654
58 certified beds For profit - Limited Liability company Chain: Serrano Group
- No federal fines or payment denials in CMS’s 3-year window.
The composite number cleared 72 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.40 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.49 | 0.55–0.75 |
| Weekend hours / resident-day | 3.72 | ≈ weekday level |
| Nursing turnover / year | 49% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (40 in the current record)
-
Potential for harm · F December 23, 2025 · found via complaint
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.
Corrected January 16, 2026 · Nursing and Physician Services
-
Potential for harm · E October 28, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 21, 2025 · Quality of Life and Care
-
Potential for harm · D September 19, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D September 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D September 19, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 19, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D September 10, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 25, 2025 · Quality of Life and Care
-
Potential for harm · D July 31, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 20, 2025 · Quality of Life and Care
-
Potential for harm · D May 30, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected June 19, 2025 · Resident Rights
-
Potential for harm · D May 30, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected June 20, 2025 · Resident Rights
-
Potential for harm · E May 30, 2025
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.
Corrected June 19, 2025 · Resident Rights
-
Potential for harm · D May 30, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected June 19, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D May 30, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected June 9, 2025 · Quality of Life and Care
-
Potential for harm · D May 30, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected June 3, 2025 · Quality of Life and Care
-
Potential for harm · D May 30, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 19, 2025 · Pharmacy Service
-
Potential for harm · D May 30, 2025
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.
Corrected May 30, 2025 · Pharmacy Service
-
Potential for harm · E May 30, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 19, 2025 · Nutrition and Dietary
-
No harm found · B May 30, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected May 30, 2025 · Environmental
-
Potential for harm · E June 16, 2024
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.
Corrected July 1, 2024 · Resident Rights
-
Potential for harm · D June 16, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 3, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D June 16, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 5, 2024 · Quality of Life and Care
-
Potential for harm · E June 16, 2024
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected July 8, 2024 · Quality of Life and Care
-
Potential for harm · E June 16, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected July 3, 2024 · Quality of Life and Care
-
Potential for harm · D June 16, 2024
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected July 8, 2024 · Nutrition and Dietary
-
Potential for harm · D June 16, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected July 1, 2024 · Resident Assessment and Care Planning
-
No harm found · B June 16, 2024
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected July 1, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055541 · certified since May 30, 1996. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.