Complaint Investigation

Greenfield Care Center Of South Gate

February 3, 2025 · South Gate, CA · 8455 State Street

Citations 2

CMS Rating 1/5

Beds 99

Provider ID 056458

Healthcare Facility

Greenfield Care Center Of South Gate

South Gate, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 4 pages

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

GREENFIELD CARE CENTER OF SOUTH GATE in SOUTH GATE, CA — inspection on February 3, 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

FF609

F-F609.

056458

FF610

TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47858 Few Abuse and Neglect Prevention, when the following occurred for one out of three sampled residents (Resident affected

During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 1 ' s cognitive skills (ability to think and reason) for daily decision making was severely impaired.

The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and, or touching as resident completes activity) for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.

During a review of Resident 1 ' s Nursing Progress Notes, dated 1/19/2025, the progress note indicated Resident 1 ' s son made the facility aware that his mother told him a nurse was too rough on her (Resident 1) last night.

The progress notes indicated Resident 1 stated a male CNA (CNA 1) was rough with her, hurt Resident 1 ' s arm, and cleaned Resident 1 with hot water last night.

During a review of the facility ' s Five-Day Investigation Report, dated 1/22/2025, the report indicated CNA 1 asked CNA 2 to translate (in Spanish) for Resident 1 when Resident 1 became agitated.

The report indicated Resident 1 told CNA 2 that CNA 1 was rough (during care).

During an interview, on 2/3/2025, at 11:51 a.m., with CNA 2, CNA 2 stated, during the 11 p.m.- 7 a.m. shift, on 1/19/2025, she helped translate for CNA 1 and Resident 1. CNA 2 stated Resident 1 told her CNA 1 was too rough and Resident 1 wanted a pain pill because her left arm was hurting after CNA 1 repositioned her. CNA 2 stated that she only told LVN 1 Resident 1 wanted her pain pill, but did not report Resident 1 ' s complaint about CNA 1. CNA 2 stated she should have told LVN 1 or notified the proper agencies (CPDH, law enforcement, and the ombudsman) about Resident 1 ' s concern because it was considered an abuse allegation. CNA 2 stated this delayed the facilities ' ability to investigate timely and prevent Resident 1 from possible further abuse.

056458

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056458 B.

Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

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 SOUTH GATE, 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 GREENFIELD CARE CENTER OF SOUTH GATE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.