Facility WatchInspection records for every certified US nursing home
Royal Oaks Manor-bradbury Oaks
1763 Royal Oaks Drive Duarte, CA 91010 (626) 359-9371
CCN
555503
Certified beds
48
Ownership
Non profit - Corporation
Chain
Humangood
Nurse staffing
4.84
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.55 hours per resident per day
Nursing staff turnover: 28% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected January 2, 2026
8 citations · Health
D
F0550No 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 January 22, 2026
D
F0644No actual harm with potential for more than minimal harm · Isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Deficient, Provider has date of correction · corrected January 15, 2026
D
F0684No 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 January 16, 2026
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected January 15, 2026
E
F0578No 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 January 21, 2026
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected January 7, 2026
E
F0755No actual harm with potential for more than minimal harm · Pattern
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 February 19, 2026
E
F0880No 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 January 8, 2026
Inspected December 1, 2025
2 citations · from a complaint investigation · Health
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected December 5, 2025
E
F0919No actual harm with potential for more than minimal harm · Pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected December 5, 2025
Inspected November 15, 2024
13 citations · Health
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected December 15, 2024
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected December 15, 2024
D
F0684No 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 December 15, 2024
D
F0689No 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 December 15, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Deficient, Provider has date of correction · corrected December 15, 2024
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected December 15, 2024
D
F0761No 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 December 15, 2024
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected December 15, 2024
E
F0656No 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 December 15, 2024
E
F0700No actual harm with potential for more than minimal harm · Pattern
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Deficient, Provider has date of correction · corrected December 15, 2024
E
F0842No actual harm with potential for more than minimal harm · Pattern
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 December 15, 2024
E
F0880No 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 December 15, 2024
E
F0919No actual harm with potential for more than minimal harm · Pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected December 15, 2024
Inspected October 5, 2024
1 citation · from a complaint investigation · Health
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected October 24, 2024
Inspected May 10, 2024
1 citation · from a complaint investigation · Health
G
F0689Actual 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 May 29, 2024
Inspected April 15, 2024
1 citation · from a complaint investigation · Health
G
F0744Actual harm · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected May 10, 2024
Inspected November 28, 2023
1 citation · from a complaint investigation · Health
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 11, 2023
Inspected November 2, 2023
15 citations · Health
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected November 20, 2023
D
F0573No actual harm with potential for more than minimal harm · Isolated
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Deficient, Provider has date of correction · corrected November 20, 2023
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected November 10, 2023
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected November 9, 2023
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected November 20, 2023
D
F0758No actual harm with potential for more than minimal harm · Isolated
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Deficient, Provider has date of correction · corrected November 20, 2023
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected November 14, 2023
E
F0550No actual harm with potential for more than minimal harm · Pattern
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 November 6, 2023
E
F0655No actual harm with potential for more than minimal harm · Pattern
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected November 10, 2023
E
F0656No 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 November 10, 2023
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected November 22, 2023
E
F0689No 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 16, 2023
E
F0760No actual harm with potential for more than minimal harm · Pattern
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected November 14, 2023
E
F0812No 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 November 14, 2023
E
F0880No 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 November 2, 2023