Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Acres Healthcare Center during CMS and state inspections, most recent first.
The facility failed to monitor and document refrigerator temperatures in the temporary food storage room, risking foodborne illness for residents. Temperature logs for one refrigerator and the freezer were left blank for several days, contrary to the facility's policy requiring daily checks. The Dietary Service Supervisor was unsure if the designated staff had performed the required checks.
A facility failed to obtain informed consent for psychotropic medications for a resident with dementia and schizophrenia, and did not ensure POLST forms for three residents were properly completed and signed. The omissions in documentation could lead to delays in care during emergencies, as POLST forms serve as physician orders. The facility's policies for informed consent and POLST completion were not followed, violating residents' rights to be informed and make decisions about their care.
The facility failed to maintain resident dignity and effective communication, as seen in two cases. A resident with a suprapubic catheter was observed without a urinary bag cover, violating privacy. Another resident, hard of hearing and speaking a foreign language, faced communication barriers due to inadequate tools and methods, leading to frustration and unmet needs. Staff acknowledged these issues, which contravened facility policies on resident rights and dignity.
The facility failed to ensure Advance Directives (AD) were offered and documented for two residents, one with bipolar disorder and schizophrenia, and another with pneumonia and schizophrenia. Despite intact cognition, neither resident had an AD or POLST in their records. Staff interviews revealed confusion about responsibility for ADs, and the medical records director admitted oversight, contrary to facility policy requiring inquiry and assistance with ADs upon admission.
The facility failed to develop comprehensive care plans for two residents, one with aggressive behavior and another with communication barriers. Despite incidents of aggression and communication difficulties, the facility did not create adequate care plans, leading to unmet needs and compromised resident rights.
A resident with hearing difficulties and language barriers did not receive necessary assistive devices or an audiology consult, despite a physician's order. Staff were aware of the resident's communication challenges but did not provide effective solutions, leading to impaired communication and delayed care. The facility's policy on accommodating communication deficits was not followed.
A resident with a suprapubic catheter was at risk for UTIs due to improper catheter care. The drainage bag was observed hanging higher than the bladder, and the tubing was wrapped around the resident's leg, both of which could cause urine backflow. Staff acknowledged these practices were inappropriate, and the facility's policies emphasize proper positioning to prevent infections.
A facility failed to refer a resident with schizophrenia for a psychiatric consultation despite documented aggressive behavior and a care plan intervention. The resident's aggressive actions were noted in assessments, but the facility overlooked the necessary referral, contrary to its behavioral health services policy.
A facility failed to maintain a medication error rate below 5%, reaching 13.79% during a medication pass. An LVN crushed and mixed four medications for a resident with bipolar disorder and schizophrenia, contrary to best practices. The DON confirmed that medications should be administered separately unless preferred otherwise. The facility's policy lacked specific guidance on administering crushed medications.
The facility failed to properly store medications by placing Hydrogen Peroxide Topical Solution, an external medication, on the same shelf as oral medications. This was observed during an inspection with an LVN, who confirmed the improper storage. The DON acknowledged the risk of misidentification and accidental ingestion due to similar container appearances. The facility's policy requires separate storage for oral and external medications.
A resident with a suprapubic catheter on Enhanced Barrier Precautions received high-contact care from an LVN and a CNA who failed to wear isolation gowns and perform hand hygiene, contrary to the facility's Infection Prevention and Control Program. The resident had a history of urinary issues and cognitive impairment, necessitating strict adherence to PPE protocols to prevent infection spread.
The facility was found to have three rooms each accommodating five residents, exceeding the regulatory limit of four residents per room. Despite a waiver request and no reported concerns from residents or staff about space, the setup did not comply with regulations. Interviews confirmed residents had intact cognitive skills and required assistance with daily activities, but the room arrangement still constituted a deficiency.
The facility failed to meet the required room size of 100 sq. ft. for four single resident rooms, with Rooms 4 and 5 measuring 76 sq. ft. and Rooms 16 and 17 measuring 99.75 sq. ft. Despite this, observations and interviews indicated that the room sizes did not affect the care provided. A resident with schizophrenia, hypertension, and anxiety disorder reported having enough space, and staff confirmed sufficient space for care delivery.
The facility failed to provide direct exit access for four resident rooms, requiring residents to pass through other rooms to reach an exit corridor. Although the residents were ambulatory and reported no issues, this arrangement potentially compromised their safety in emergencies. Interviews with staff and a resident confirmed the current setup, and a room variance indicated no adverse effects on residents' health and safety.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures in the temporary food storage room, which placed residents at risk for foodborne illness. During a follow-up kitchen tour, it was observed that the temperature logs for one of the refrigerators and the freezer were not filled out for several days. Specifically, the log for Refrigerator 2 was blank from the afternoon of February 4th to February 6th, and the logs for Refrigerator 3 and the freezer were blank for the same period. The Dietary Service Supervisor (DSS) indicated that the responsibility for checking and logging the temperatures of the refrigerators and freezers fell to the cooks on both the AM and PM shifts. However, the DSS was unsure if the cooks had checked the logs, and acknowledged that the logs should not have been missed. The facility's policy requires daily temperature checks and documentation at the first opening and at closing in the evening, but this procedure was not followed, leading to the deficiency.
Failure to Obtain Informed Consent and Complete POLST Forms
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding informed consent for medications and life-sustaining treatment orders. Resident 37, who was diagnosed with dementia, psychotic disorder, and schizophrenia, was prescribed Quetiapine and Divalproex Sodium without obtaining informed consent from the resident's representative or power of attorney. The facility's policy required the prescriber's signature on the informed consent within 24 hours of admission, but this was not completed, leaving the resident's representative unaware of the medication's risks, benefits, and alternatives. Additionally, the facility did not ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 12, 69, and 14 were properly completed and signed by the responsible parties. Resident 12, with a moderately impaired cognitive status, had a POLST indicating DNR status, but it lacked the responsible party's signature, rendering it invalid. Similarly, Resident 69's POLST was missing the responsible party's signature, and Resident 14's POLST was prepared without obtaining the resident's signature. These omissions could lead to delays in care during emergencies, as the POLST forms serve as physician orders for medical professionals. The facility's policies and procedures for informed consent and POLST completion were not followed, resulting in incomplete documentation and potential delays in care. The Director of Nurses and other staff acknowledged the deficiencies, noting the importance of having valid POLST forms and informed consent to ensure residents and their representatives are aware of treatment options and preferences. The lack of proper documentation violated residents' rights to be informed and make decisions about their care, potentially affecting their quality of life and health outcomes.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two specific incidents involving Resident 3 and Resident 226. Resident 3, who had a suprapubic catheter, was observed without a urinary catheter bag cover, which is a violation of privacy and dignity. The staff, including a CNA and an LVN, acknowledged the absence of the cover and recognized it as a breach of the resident's rights. The facility's policy mandates that urinary catheter bags should be covered to maintain resident dignity. Resident 226, who was hard of hearing and spoke a foreign language, experienced significant communication barriers with the staff. The resident expressed frustration and sadness due to the inability to communicate effectively, as the staff did not provide adequate means of communication such as a communication board or appropriate translation services. Interviews with various staff members, including CNAs and LVNs, revealed that the facility did not have effective communication tools in place, and the staff often resorted to ineffective methods like body language or phone translation, which were not suitable given the resident's hearing impairment. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect and ensuring effective communication. However, the lack of proper assessment and implementation of communication strategies for Resident 226, along with the failure to maintain privacy for Resident 3, demonstrate a disregard for these policies. The Director of Nursing acknowledged the deficiencies and the impact on resident rights, highlighting the need for comprehensive care plans and effective communication methods.
Failure to Implement Advance Directive Policy
Penalty
Summary
The facility failed to implement its policy and procedure on Advance Directives (AD) by not ensuring that the AD was offered, explained, and signed for two residents. Resident 14, admitted with diagnoses including bipolar disorder and schizophrenia, had intact cognition according to the Minimum Data Set (MDS) but did not have an AD in their medical records or the facility's database. There was no documentation indicating that the facility offered an AD during Resident 14's admission. Similarly, Resident 39, who was readmitted with pneumonia and schizophrenia, also lacked an AD or a Physician's Orders for Life-Sustaining Treatment (POLST) in their records. Although initially noted as lacking decision-making capacity, the MDS indicated intact cognition. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring ADs and POLSTs were in place, with the medical records director admitting oversight. The facility's policy requires the social services director or designee to inquire about ADs upon admission and assist in establishing them if needed, which was not followed in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in care. Resident 9, who was diagnosed with schizophrenia and had intact cognition, exhibited aggressive behavior towards staff and other residents. Despite multiple incidents of aggression and attempts to take personal belongings from other residents, the facility did not create a care plan to address these behaviors. Interviews with staff revealed that although Change of Condition assessments were initiated, no interdisciplinary team meeting or care plan was developed to ensure the safety and dignity of all residents. Resident 226, who was admitted with Type 2 Diabetes Mellitus, dementia, and hearing difficulties, faced communication barriers due to a language difference and hearing impairment. The resident expressed frustration over the inability to communicate effectively with staff, which was exacerbated by the lack of a communication board or other aids. Staff interviews confirmed that communication methods were inadequate, and there was no documented evidence of translation services or communication aids being provided. The facility's failure to assess and address these communication needs resulted in unmet care needs and compromised resident rights. The facility's policy required the development of a comprehensive, person-centered care plan that includes measurable objectives and timeframes. However, the facility did not adhere to this policy for either resident, resulting in deficiencies that affected the residents' physical, mental, and psychosocial well-being. The Director of Nursing acknowledged the lapses in care planning and communication, emphasizing the importance of effective communication and comprehensive care planning to uphold resident rights and ensure their well-being.
Failure to Provide Hearing Assistive Devices for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper assistive devices to maintain hearing abilities, resulting in a delay of services for the resident. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, unspecified dementia, and abnormalities of gait and mobility, was observed having difficulty hearing and communicating with staff. Despite a physician's order for an audiology consult as needed for hearing problems, the facility did not arrange for this referral, leading to the resident's inability to hear adequately during interactions with staff. Interviews with staff revealed that they were aware of the resident's hearing difficulties and language barriers, yet no effective communication methods or assistive devices were provided. The Social Service Director stated that no hearing disability was reported upon admission, and the Director of Nursing acknowledged the failure to assess and address the resident's communication needs. The facility's policy on accommodating communication deficits was not followed, as the resident's needs for adaptive devices and modifications were not evaluated or addressed, impairing the resident's ability to communicate effectively and maintain dignity.
Improper Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for a resident with a suprapubic catheter. On two separate occasions, the resident's catheter drainage bag was improperly positioned, which could lead to backflow of urine and potential UTIs. On the first occasion, the drainage bag was observed hanging on the wheelchair's armrest, higher than the resident's bladder, contrary to the facility's policy that requires the bag to be positioned lower than the bladder. On another occasion, the resident's catheter tubing was found wrapped around their leg, which could impede urine flow and cause backflow. Both the Registered Nurse and Licensed Vocational Nurse acknowledged that these practices were inappropriate and could lead to UTIs. The facility's Infection Preventionist and Director of Nurses confirmed that the drainage bag should always be below the bladder and the tubing should not be wrapped around the leg to prevent backflow and potential infections. The resident involved had a history of urinary tract infections and was diagnosed with conditions such as benign prostatic hyperplasia and obstructive and reflux uropathy, which necessitated the use of a suprapubic catheter. The facility's policies on suprapubic catheter care and infection prevention emphasize the importance of proper catheter positioning to prevent infections, but these were not adhered to in the resident's care.
Failure to Provide Psychiatric Referral for Aggressive Resident
Penalty
Summary
The facility failed to implement its policy and procedure on behavioral health services by not providing a referral for a psychiatric consultation for a resident exhibiting aggressive behavior. The resident, who was diagnosed with schizophrenia, was readmitted to the facility and had intact cognition according to the Minimum Data Set. Despite the creation of a care plan on January 28, 2025, which included an intervention for a psychiatric consultation, the facility overlooked this intervention and did not refer the resident to a psychiatrist. The resident's aggressive behavior was documented in Change of Condition assessments on January 16 and January 28, 2025, indicating attempts to attack staff and residents and taking personal belongings from another resident. Interviews with Licensed Vocational Nurses and the Director of Nursing confirmed the oversight in referring the resident for psychiatric evaluation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that residents should receive necessary behavioral services to maintain their highest practicable well-being, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass, resulting in a 13.79% error rate. This was observed during a medication administration for one of the residents, who was diagnosed with bipolar disorder and schizophrenia, and had severely impaired cognition. The resident was prescribed several medications, including Depakote Sprinkles, Docusate Sodium, Multivitamin-Minerals, and Sodium Chloride. During the medication administration, an LVN prepared and crushed four oral medications, mixing them in a single container with applesauce. The surveyor intervened before the medications were administered. The LVN acknowledged the mistake, stating that the resident would not know what medication they were taking if mixed together. The DON later confirmed that medications should ideally be administered separately unless the resident prefers otherwise. The facility's medication administration policy lacked specific instructions on administering crushed medications.
Improper Storage of Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the proper and safe storage of medications and biologicals. During an inspection of the East Wing medication storage room, a bottle of Hydrogen Peroxide Topical Solution, which is an external medication, was found stored on the same shelf as oral medications, such as stool softeners and vitamins. This observation was made in the presence of an LVN, who acknowledged that external medications should not be stored with oral medications to prevent medication errors. The Director of Nursing (DON) confirmed that oral and external medications should be stored separately to avoid the risk of misidentification and accidental ingestion, especially if the containers are similar in appearance. The DON was unaware of who placed the external medication on the shelf with oral medications. A review of the facility's medication storage policy, effective since April 2008, indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, specifically in the case of a resident with a suprapubic catheter who was on Enhanced Barrier Precautions (EBP). During an observation, it was noted that a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA) provided high-contact care to the resident without wearing the required isolation gowns as part of their Personal Protective Equipment (PPE). Additionally, both staff members did not perform hand hygiene after completing the care and proceeded to the nurses' station, which was against the facility's policy. The resident involved had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary tract infections, and was cognitively impaired, requiring assistance with daily activities. The care plan for the resident included Enhanced Barrier Precautions due to the use of a suprapubic catheter, which required staff to use gloves, gowns, and masks during direct care and to perform hand hygiene before and after care. Despite these clear directives, the staff failed to comply with the necessary precautions. Interviews with the involved staff and facility leadership confirmed awareness of the requirements for PPE and hand hygiene. The LVN admitted to forgetting to wear a gown and perform hand hygiene, while the CNA could not provide a reason for the oversight. The Infection Preventionist and Director of Nurses reiterated the importance of following the EBP policy to prevent the spread of infections, highlighting the potential risk posed by the staff's non-compliance with established protocols.
Facility Exceeds Resident Room Capacity Limits
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as three rooms (Rooms 6, 15, and 26) each accommodated five residents, exceeding the maximum of four residents per room. This deficiency was identified through observation, interviews, and record reviews. The rooms in question had varying square footage, with Room 6 at 332.5 sq. ft, Room 15 at 441 sq. ft, and Room 26 at 496 sq. ft. Despite the facility's submission of a room waiver request, which claimed no adverse effects on residents' health, safety, or welfare, the setup did not align with the regulatory standards. Interviews with residents and staff revealed that the residents did not express concerns about the room space or sharing with others. Residents 67, 36, and 20, who were interviewed, all had intact cognitive skills and required varying levels of assistance with daily activities. They reported having enough room to perform their activities and did not mind sharing their rooms. Staff members, including a CNA and an LVN, also indicated that they had sufficient space to provide care and had not received complaints from residents regarding room space. However, the facility's arrangement still constituted a regulatory deficiency due to the number of residents per room exceeding the allowed limit.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that four single resident rooms met the required minimum size of 100 square feet per resident. Specifically, Rooms 4 and 5 measured 76 square feet each, while Rooms 16 and 17 measured 99.75 square feet each. This deficiency was identified through a review of the facility's Client Accommodation Analysis and a waiver request submitted by the Administrator. The report indicates that the room sizes did not meet the Centers for Medicare & Medicaid Services (CMS) requirements, potentially affecting the quality of care, health, and safety of the residents due to inadequate space for care, mobility, and privacy. Despite the deficiency, observations and interviews conducted on February 7, 2025, revealed that the room sizes did not negatively impact the care and services provided to the residents. Residents and staff reported having sufficient space for care delivery and daily activities. Resident 8, who has a history of schizophrenia, hypertension, and anxiety disorder, stated she had enough space in her room and did not experience any issues with her care. Similarly, a CNA and an LVN confirmed that they had enough space to perform their duties in the single rooms and had not received any complaints from residents.
Deficiency in Direct Exit Access for Resident Rooms
Penalty
Summary
The facility failed to ensure that four resident bedrooms (Rooms 4, 5, 16, and 17) had direct access to an exit corridor without passing through another resident's bedroom. This deficiency was identified during a facility tour, where it was observed that residents in these rooms had to pass through adjacent rooms to reach the nearest exit corridor. This practice potentially compromised the privacy, health, and safety of the residents, particularly in emergency situations where direct access to an exit is crucial. Despite the lack of direct access, the residents in these rooms were ambulatory and did not express any concerns about their room locations. Interviews with a resident and staff members, including a CNA and an LVN, indicated that the residents were able to move in and out of their rooms without issues. Additionally, a room variance received during the survey period suggested that the residents' needs were accommodated without adverse effects on their health, safety, and welfare. However, the facility's arrangement still posed a potential risk due to the lack of direct exit access.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rosemead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Gabriel Conv Center | 0 mi | — | 0 | 0 |
| Monterey Healthcare & Wellness Centre, Lp | 0.1 mi | — | 22 | 0 |
| Del Mar Convalescent Hospital | 1.5 mi | — | 19 | 0 |
| Rio Hondo Subacute & Nursing Center | 2.1 mi | — | 44 | 0 |
| Monterey Park Conv Hosp | 2.2 mi | — | 0 | 0 |
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