Greenfield Care Center of South Gate

In the surveyor’s words

From the most serious findings on record at Greenfield Care Center of South Gate, in the surveyor’s own words.

• Actual harm, isolatedF688May 31, 2024

  Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of four sampled residents (Resident 53) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility by failing to: 1. Monitor Resident 53's ROM in each joint of both arms and legs upon admission, quarterly, and annually in accordance with the facility's policies and procedures (P&P) titled, Resident Mobility and Range of Motion, which indicated the resident's comprehensive assessment will identify a resident's current range of motion of his or her joints. 2. […]

• Actual harm, isolatedF825May 31, 2024

  Based on observation, interview, and record review, the facility failed to provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) to one of four sampled residents (Resident 53), who had range of motion (ROM, full movement potential of a joint [where two bones meet]) mobility (ability to move) and swallowing problems. The facility failed to: 1. […]

• Actual harm, isolatedF689Mar 31, 2023

  Based on interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 provided care and services to prevent an injury for one of three sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when using a Hoyer Lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from Resident 1 ' s bed to the wheelchair. 2. […]

• Actual harm, isolatedF689Jun 17, 2022

  Based on observation, interview and record review the facility failed to ensure Certified Nurse Assistants (CNA 1), CNA 2, and CNA 3, did not use a frayed, worn-out sling (accessory attached to a mechanical lift [mechanical device used to transfer a resident between surfaces while supporting the resident's weight and providing stability]) to transfer the resident from a wheelchair to bed for one of one resident (Resident 1). The facility failed to: 1. Ensure laundry workers checked lift ' s slings daily after wash and air dry to identify bleached stains, tears, or any signs of sling ' s fragility and wear and tear in accordance with the facility ' s policy titled, ' Mechanical Lift Policy. ' 2. […]

• No harm, potential for more than minimal, widespreadF880Jul 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control measures were maintained and/or implemented for eight of 19 sampled residents (Residents 71, 70, 74, 1, 18, 52, 5, and 20) when: 1. Signage for enhanced barrier precautions (EBP, infection control measures used to reduce the spread of multidrug-resistant organisms [MDROs], requiring staff to wear a protective gown and gloves during high-contact activity) was not placed outside of Rooms A, B, and C.2. Certified Nursing Assistant (CNA) 2 and CNA 3 did not don the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Room D.3. […]