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
Registered name: ROYAL OAKS MANOR-BRADBURY OAKS
DUARTE, CA · Medicare-certified · 48 beds
In good standing
Non-profitChain member
Data as of July 1, 2026
4 of 5 overall
Royal Oaks in Duarte has an overall rating of 4 out of 5 stars, with strong staffing (5 stars) and quality measures (4 stars), though health inspections are lower at 3 stars. It reports 4.81 nursing hours per resident per day, above the federal benchmark of 4.1, and had no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
4.8073 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 4.8073.
Staffing detail
- Registered nurses
- 0.61
- Licensed practical nurses
- 1.53
- Nurse aides
- 2.67
- Weekend nursing
- 4.44
Hours per resident per day.
Total staff turnover: 31%
Registered nurse turnover: 38%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
22.7%17.9%Improving
Residents with a fall causing major injury
0%0%No change
Residents with pressure ulcers (bedsores)
5.2%12.9%Worsening
Residents with a urinary tract infection
7.7%3.1%Improving
Residents who lost too much weight
0%0%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
19%18.2%Improving
Long-stay residents on antianxiety or sleep medication
4%3.4%Improving
Short-stay residents newly given an antipsychotic
2%3.9%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
39.6%20.3%Improving
Residents with depressive symptoms
3.4%3.4%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—93.9%—
Short-stay residents given the pneumonia vaccine
92%83.8%Worsening
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.
View the original federal record
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.
View the original federal record
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
- 43.1 residents on an average day (90% 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.