Greenfield Care Center of South Gate Complaints, Violations and Inspection Records

March 19, 2026, complaint inspection

1 deficiency cited. Surveyors cited the facility for protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

• F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (scope and severity D)

March 10, 2026, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist and provide and implement an infection prevention and control program.

• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity E)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)

February 19, 2026, complaint inspection

1 deficiency cited. Surveyors cited the facility for give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

• F0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (scope and severity D)

December 4, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that residents are fully informed and understand their health status, care and treatments.

• F0552Ensure that residents are fully informed and understand their health status, care and treatments. (scope and severity D)

November 12, 2025, complaint inspection

3 deficiencies cited. Surveyors cited the facility for protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody, timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities, and respond appropriately to all alleged violations.

• F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (scope and severity E)
• F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (scope and severity D)
• F0610Respond appropriately to all alleged violations. (scope and severity D)

September 12, 2025, complaint inspection

2 deficiencies cited. Surveyors cited the facility for ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being and protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

• F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (scope and severity E)
• F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (scope and severity D)

July 18, 2025, standard inspection

18 deficiencies cited. Surveyors cited the facility for provide and implement an infection prevention and control program, develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, and provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0880Provide and implement an infection prevention and control program. (scope and severity F)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity E)
• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity E)
• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity D)
• F0552Ensure that residents are fully informed and understand their health status, care and treatments. (scope and severity D)
• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity D)
• F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (scope and severity D)
• F0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (scope and severity D)
• F0641Ensure each resident receives an accurate assessment. (scope and severity D)
• F0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (scope and severity D)

• F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing. (scope and severity D)
• F0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (scope and severity D)
• F0692Provide enough food/fluids to maintain a resident's health. (scope and severity D)
• F0695Provide safe and appropriate respiratory care for a resident when needed. (scope and severity D)
• F0700Try 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. (scope and severity D)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity D)
• F0757Ensure each resident’s drug regimen must be free from unnecessary drugs. (scope and severity D)
• F0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (scope and severity D)

July 9, 2025, complaint inspection

5 deficiencies cited. Surveyors cited the facility for let each resident or the resident's legal representative access or purchase copies of all the resident's records, timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities, and develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

• F0573Let each resident or the resident's legal representative access or purchase copies of all the resident's records. (scope and severity D)
• F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (scope and severity D)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)
• F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (scope and severity D)

June 12, 2025, complaint inspection

2 deficiencies cited. Surveyors cited the facility for immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident and develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

• F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (scope and severity D)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)

June 3, 2025, complaint inspection

2 deficiencies cited. Surveyors cited the facility for develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured and provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity D)

April 14, 2025, complaint inspection

2 deficiencies cited. Surveyors cited the facility for honor the resident's right to be treated with respect and dignity and to retain and use personal possessions and timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

• F0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (scope and severity D)
• F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (scope and severity D)

April 8, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide safe, appropriate dialysis care/services for a resident who requires such services.

• F0698Provide safe, appropriate dialysis care/services for a resident who requires such services. (scope and severity D)

February 3, 2025, complaint inspection

2 deficiencies cited. Surveyors cited the facility for timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities and respond appropriately to all alleged violations.

• F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (scope and severity D)
• F0610Respond appropriately to all alleged violations. (scope and severity D)

December 27, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)

November 13, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity D)

October 22, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for ensure services provided by the nursing facility meet professional standards of quality and ensure that residents are free from significant medication errors.

• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)
• F0760Ensure that residents are free from significant medication errors. (scope and severity D)

July 24, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide and implement an infection prevention and control program and honor each resident's preferences, choices, values and beliefs.

• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0675Honor each resident's preferences, choices, values and beliefs. (scope and severity D)

May 31, 2024, standard inspection

26 deficiencies cited. Surveyors cited the facility for provide appropriate care for a resident to maintain and/or improve range of motion (rom), limited rom and/or mobility, unless a decline is for a medical reason, provide or get specialized rehabilitative services as required for a resident, and ensure a qualified health professional conducts resident assessments.

• F0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (scope and severity G)
• F0825Provide or get specialized rehabilitative services as required for a resident. (scope and severity G)
• F0642Ensure a qualified health professional conducts resident assessments. (scope and severity E)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity E)
• F0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (scope and severity E)
• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity E)
• F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing. (scope and severity E)
• F0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (scope and severity E)
• F0700Try 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. (scope and severity E)
• F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (scope and severity E)
• F0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (scope and severity E)
• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity E)

• F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (scope and severity E)
• F0865Have a plan that describes the process for conducting QAPI and QAA activities. (scope and severity E)
• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0919Make sure that a working call system is available in each resident's bathroom and bathing area. (scope and severity E)
• F0552Ensure that residents are fully informed and understand their health status, care and treatments. (scope and severity D)
• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity D)
• F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (scope and severity D)
• F0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (scope and severity D)
• F0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (scope and severity D)
• F0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (scope and severity D)
• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity D)
• F0758Implement 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. (scope and severity D)
• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity D)
• F0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (scope and severity D)

December 7, 2023, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide and implement an infection prevention and control program and develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)

November 21, 2023, complaint inspection

2 deficiencies cited. Surveyors cited the facility for not require residents to give up medicare or medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide and ensure services provided by the nursing facility meet professional standards of quality.

• F0620Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. (scope and severity D)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)

August 3, 2023, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide and implement an infection prevention and control program.

• F0880Provide and implement an infection prevention and control program. (scope and severity D)

March 17, 2022, standard inspection

18 deficiencies cited. Surveyors cited the facility for procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards, ensure each resident receives an accurate assessment, and provide care and assistance to perform activities of daily living for any resident who is unable.

• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity F)

• F0641Ensure each resident receives an accurate assessment. (scope and severity E)
• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity E)
• F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing. (scope and severity E)
• F0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (scope and severity E)
• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity E)
• F0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. (scope and severity E)
• F0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (scope and severity E)
• F0909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. (scope and severity E)
• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity D)
• F0583Keep residents' personal and medical records private and confidential. (scope and severity D)
• F0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (scope and severity D)
• F0637Assess the resident when there is a significant change in condition (scope and severity D)
• F0697Provide safe, appropriate pain management for a resident who requires such services. (scope and severity D)
• F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (scope and severity D)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity D)
• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity D)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)