Royal Oaks Manor-bradbury Oaks
ROYAL OAKS MANOR-BRADBURY OAKS in DUARTE, CA — inspection on December 1, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's Medication Administration Record (MAR) for 11/1/2025 to 11/30/2025, the MAR indicated Resident 1 received morphine sulfate (pain medication for the severe pain) on the following dates:11/22/2025 at 11:20 AM for a pain level of 9/10 (9/10 indicates very severe pain. A numeric pain scale is a tool to rate pain using numbers from 0 to 10, where 0 indicates no pain, 10 indicates worst pain imaginable).11/23/2025 at 8:35 AM and 5:48 PM for a pain level of 8/10 and 9/10.11/24/2025 at 8:40 AM, 11:19 AM, and 9:32 PM for a pain level of 9/10, 8/10, and 7/10.11/25/2025 at 7:46 AM for a pain level of 6/10.
During a review of the facility's Policy and Procedure (P&P), titled Hospice Program, revised on July 2017, the P&P indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
These responsibilities include administering prescribed therapies.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive Duarte, CA 91010
SUMMARY STATEMENT OF DEFICIENCIES
During a review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment tool) dated 11/7/2025, the MDS indicated Resident 2 had intact cognition and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with sit-to-stand and dependent with rolling left and right and lying-to-sitting.
During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 11/14/2025, with diagnoses that included fusion of spine, lumbar region (surgery that connects two or more bones in the spine) and muscle weakness.
During an interview on 11/25/2025 at 11:40 AM, Resident 2's Family member (FM 1) stated sometimes staff would take an hour to respond to the call light. FM 1 stated FM 1 would be the one who would assist Resident 2 to the bathroom when staff response was taking too long.
During an interview on 11/25/25 at 11:47 AM, Resident 3 stated the resident had been at the facility for two weeks and there were two (2) times it took the facility staff an hour to respond to the call light, it happened once at night and once during the day. Resident 3 stated last night and this morning it was better because facility staff responded within 10-15 minutes. Resident 3 stated the resident would check the clock in front of Resident 3's bed. Resident 3 stated on those two times, no staff came to check what Resident 3 needed. Resident 3 stated the resident would usually call for assistance to the bathroom.
During an interview on 11/25/2025 at 1:12 PM, Certified Nursing Assistant (CNA) 3 stated when call lights were pressed, staff needed to go immediately and if not possible, another staff needed to go and check because the call might be an emergency.
During an interview on 11/25/2025 at 3:18 PM, Licensed Vocational Nurse (LVN) 2 stated call lights needed to be answered immediately because the call might be an emergency situation, an example would be difficulty breathing.
During a review of the facility's Resident Council Meeting minutes indicated the following:On 7/29/2025, residents in attendance stated call lights were not answered timely during the 11:00 PM to 7:00 AM shift.On 9/30/2025, two residents stated call lights were answered, but the needs of the residents were not met.
During a review of the facility's Policy and Procedure (P&P), titled Answering the Call Light, revised on September 2022, the P&P indicated, Answer the resident call system immediately.
When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?).
The P&P indicated:a. If the resident needs assistance, indicate the approximate time it will take for you to respond.b.
If the resident's request requires another staff member, notify the individual.c. If the resident's request is something you can fulfill, complete the task within five minutes if possible.d. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.
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