Public Record
Royal Oaks Manor-bradbury Oaks
Operated by Humangood
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 48
- Avg. residents per day
- 44
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 42
- Fire safety findings
- 9
- Inspections on file
- 11
- Last inspection
- 2026-01-02
*CMS
*CMS
*CMS
*CMS
Citations
42 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0578Generalpotential for harm
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.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0700Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0761Generalpotential for harm
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.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0744Seriousactual harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0758Generalpotential for harm
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.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0573Generalpotential for harm
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection8 deficiencies
555503 01/02/2026 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
- Inspection2 deficiencies
555503 12/01/2025 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record…
Read full statement of deficiencies - View inspection reportInspectionFire Safety5 deficiencies
- Inspection13 deficiencies
555503 11/15/2024 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that…
Read full statement of deficiencies - Inspection1 deficiency
555503 10/05/2024 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review…
Read full statement of deficiencies - Inspection1 deficiency
555503 05/10/2024 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS…
Read full statement of deficiencies - Inspection1 deficiency
555503 04/15/2024 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Actual harm Based on observation, interview and record review, the facility…
Read full statement of deficiencies - Inspection1 deficiency
555503 11/28/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed…
Read full statement of deficiencies - Inspection15 deficiencies
555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010 F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or…
Read full statement of deficiencies
Showing the 10 most recent inspections. 1 earlier inspection is also on record.
Ownership
Humangood
17nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Royal Oaks Manor-bradbury Oaks?
- Royal Oaks Manor-bradbury Oaks is a Medicare- and Medicaid-certified nursing home in Duarte, CA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 555503.
- What is the CMS rating for Royal Oaks Manor-bradbury Oaks?
- Royal Oaks Manor-bradbury Oaks has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Royal Oaks Manor-bradbury Oaks have?
- Royal Oaks Manor-bradbury Oaks is certified for 48 beds. It serves an average of 44 residents per day.
- How many citations does Royal Oaks Manor-bradbury Oaks have?
- Royal Oaks Manor-bradbury Oaks has 42 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Royal Oaks Manor-bradbury Oaks last inspected?
- Royal Oaks Manor-bradbury Oaks was last inspected on January 2, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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