Royal Oaks Manor-bradbury Oaks
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
resulting a chronic pain and stiffness) of the left hip and lumbar spine. The MDS Nurse stated that holding
the left leg could be a sign the Resident 1 was experiencing pain by guarding the area that was in pain. The MDS Nurse stated residents (in general) with dementia may not always be able to verbally report pain. The MDS Nurse further stated the order for diclofenac was missed and that diclofenac could have helped with Resident 1's pain relief. 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.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Royal Oaks Manor-Bradbury Oaks
1763 Royal Oaks Drive Duarte, CA 91010
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0919
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an
interview and record review, the facility failed to ensure call lights were answered immediately for two of three sampled residents (Resident 2 and Resident 3).This deficient practice had the potential to result in residents' unmet needs.Findings: During a review of Resident 2's admission Record (AR), the AR indicated
the facility admitted Resident 2 on 11/1/2025, with diagnoses that included fracture of the right humerus (broken bone in the upper arm) and history of falling. 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.
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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ROYAL OAKS MANOR-BRADBURY OAKS in DUARTE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUARTE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ROYAL OAKS MANOR-BRADBURY OAKS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.