Greenfield Care Center Of South Gate
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident 1 and Resident 2, especially after Resident 2 climbed into Resident 1's bed and kissed him on 6/13/2025. FM 1 stated she would have felt scared if another resident kissed her and climbed into her bed.
During a concurrent interview and record review on 11/14/2025 at 3:15 p.m. with the Director of Staff Development (DSD), the facility's In-Service Binder, for 2025, was reviewed. The DSD stated following the sexual abuse in June 2025, in-services and trainings were not provided to the facility staff because she was not notified of the incident. The DSD stated staff should have been in-serviced and trained to prevent repeated sexual abuse, especially between two residents. During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is a non-consensual sexual contact of any type with a resident. The P&P indicated staff should manage the allegations by removing and protecting the residents and assessing the residents for injury and notifying the Admin. The P&P indicated after the resident has been cared for, the licensed nurse should document the resident's condition each shift for 72 hours, update the care plan with identified actions that took place, updates the 24-hour report to alert following shifts to the allegations as well as the care plan updates and communicated specific care plan updates to direct care staff.
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If continuation sheet
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
11/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenfield Care Center of South Gate
8455 State Street South Gate, CA 90280
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 F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
and Resident 2's Progress Notes, dated 6/13/2025, were reviewed. The DON stated on 6/13/2025, Licensed Vocational Nurse (LVN) 5 notified her that Resident 2 was found kissing Resident 1 and had climbed on top of him (Resident 1) in his bed. The DON stated she did not instruct LVN 5 to report the incident to the CDPH. The DON stated nonconsensual sexual contact of any type was considered sexual abuse. The DON stated Resident 2 kissing Resident 1 was considered sexual contact and sexual abuse because Resident 1 and Resident 2 had severe cognitive impairment and neither resident could consent to sexual contact. The DON stated the incident between Resident 1 and Resident 2 should have been reported to the CDPH. The DON also stated the incident on 6/13/2025 was not reported to the CDPH in part because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives. The DON stated it was important to ensure allegations of sexual abuse were reported to the CDPH for resident safety. During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Admin, Resident 2's Progress Note, dated 6/13/2025, was reviewed. The Admin stated
he was the facility's Abuse Coordinator and licensed nurses should have informed him and the CDPH of the incident (alleged sexual abuse) between Resident 1 and Resident 2 on 6/13/2025, however was not done.
During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated
she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she was a mandated reporter and should have reported the sexual abuse to the Admin and CDPH.During a review of the facility's P&P titled, Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated all facility employees are required to report any known or suspected abuse immediately upon identifying a concern. The P&P indicated all allegations of abuse will be reported to the Admin and the state survey and certification agency no later than two hours after the allegation is made.
Event ID:
Facility ID:
If continuation sheet
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
11/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenfield Care Center of South Gate
8455 State Street South Gate, CA 90280
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 F0610
F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
dated 2/2018, Resident 1's Progress Notes, dated 6/2025, Resident 1's MDS, dated [DATE REDACTED], and Resident 2's Progress Notes, dated 6/13/2025, were reviewed. The DON stated the P&P indicated nonconsensual sexual contact of any type was sexual abuse. The DON stated that both residents' progress notes indicated Resident 2 kissed Resident 1 and kissing was considered sexual contact. The DON stated Resident 1's MDS indicated Resident 1 had severe cognitive impairment. The DON stated Resident 2's MDS indicated Resident 2 had severe cognitive impairment. The DON stated neither resident could consent to sexual contact and thus the nonconsensual kissing was sexual abuse and should have been investigated according to the P&P. The DON stated Licensed Vocational Nurse 5 (LVN 5) notified her that Resident 2 kissed Resident 1 and climbed on top of him in his bed in the evening 6/13/2025. The DON stated she did not instruct LVN 5 to investigate the incident. The DON stated the incident on 6/13/2025 was not investigated because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives. The DON stated the incident should have been investigated to prevent future sexual abuse.During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Administrator (Admin), Resident 2's Progress Note, dated 6/13/2025, was reviewed. The Admin stated he was the facility's abuse coordinator and investigator. The Admin stated he should have been notified about the incident described in the progress note but was not notified. The Admin stated the incident was not investigated but should have been investigated to prevent future abuse.During an interview
on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated
she never investigated the incident, never provided a written statement, and was never interviewed about
the incident by any facility staff.During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated resident-to-resident altercations are investigated in an objective, timely, and complete manner. The P&P indicated all allegations of abuse will be investigated and the written findings of the investigation will be reported to the department of public health within five days of the alleged occurrence.
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GREENFIELD CARE CENTER OF SOUTH GATE in SOUTH GATE, 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 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.