Inspection citations
16’23
16’24
2’25
8’26
42 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jan 2, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jan 2, 2026 | E · potential | 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. | Routine |
| Jan 2, 2026 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Jan 2, 2026 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jan 2, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jan 2, 2026 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jan 2, 2026 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jan 2, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 1, 2025 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Dec 1, 2025 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Nov 15, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Nov 15, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Nov 15, 2024 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Nov 15, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Nov 15, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Nov 15, 2024 | E · potential | 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. | Routine |
| Nov 15, 2024 | D · potential | 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. | Routine |
| Nov 15, 2024 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Nov 15, 2024 | D · potential | 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. | Routine |
| Nov 15, 2024 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Nov 15, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 15, 2024 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Nov 15, 2024 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Oct 5, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| May 10, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 15, 2024 | G · harm | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Complaint |
| Nov 28, 2023 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Nov 2, 2023 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Nov 2, 2023 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| Nov 2, 2023 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Routine |
| Nov 2, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Nov 2, 2023 | E · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Nov 2, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Nov 2, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Nov 2, 2023 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Nov 2, 2023 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Nov 2, 2023 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Nov 2, 2023 | D · potential | 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. | Routine |
| Nov 2, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Nov 2, 2023 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Nov 2, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 2, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive, Duarte, CA 91010 · (626) 359-9371
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555503
- Certified beds
- 48
- Legal owner
- Humangood Socal
- Part of
- Humangood
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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