The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
ROYAL OAKS MANOR-BRADBURY OAKS
DUARTE, CA · Medicare-certified · 48 beds
In good standing
Non-profitChain member
3 of 5 overall
ROYAL OAKS MANOR-BRADBURY OAKS in Duarte, CA has a 3-star overall rating, with 4-star staffing and quality measures, 3-star health inspections, no fines in the last 24 months, and reported nurse staffing above the federal benchmark (4.74 vs 4.1 hours per resident per day).
Facility ratings
Health inspections
Staffing
4.7394 hrs/resident/day
Quality measures
Last inspection: January 2, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.7394.
Staffing detail
- Registered nurses
- 0.54
- Licensed practical nurses
- 1.51
- Nurse aides
- 2.69
- Weekend nursing
- 4.31
Hours per resident per day.
Total staff turnover: 28%
Registered nurse turnover: 44%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
20.7%Improving
Residents with a fall causing major injury
1.5%Improving
Residents with pressure ulcers (bedsores)
7.2%Worsening
Residents with a urinary tract infection
4.1%Improving
Residents who lost too much weight
9.1%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
19%Improving
Residents whose ability to walk got worse
32.4%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
5.1%Improving
Short-stay residents newly given an antipsychotic
2%Worsening
Residents with a long-term catheter
1.6%Improving
Residents with new or worsening incontinence
34.4%Worsening
Residents with depressive symptoms
3.3%Steady
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
99.2%Worsening
Short-stay residents given the seasonal flu vaccine
93.9%Steady
Short-stay residents given the pneumonia vaccine
90.3%Steady
What the inspectors found
The home failed to provide the appropriate treatment and services for a resident with dementia. Cited April 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 744 — 42 CFR §483.40(b)(3) — S/S: G
The home failed to honor residents’ choices about treatment, research participation, and advance care instructions. Cited January 2026 — limited pattern, potential for harm.
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F-Tag 578 — 42 CFR §483.10 — S/S: E
The nursing home failed to provide needed care and help with daily activities for residents who could not do them on their own. Cited January 2026 — limited pattern, potential for harm.
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F-Tag 677 — 42 CFR §483.24(a)(2) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited January 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 8 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 13 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 payment denial.
- 15 days
Medicare/Medicaid payment denial
Apr 15, 2024
Operator & ownership
- Ownership
- Non profit - Corporation
- Chain
- Part of HUMANGOOD · 17 homes · 4.5 stars avg
- Occupancy
- 44 residents on an average day (92% of 48 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 34 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.