Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Greenfield Care Center Of Fullerton, Llc during CMS and state inspections, most recent first.
The facility did not follow its own Change of Condition policy requiring every-shift assessments and documentation for 72 hours after a significant change, specifically for residents with newly identified skin issues. Three residents with impaired decision-making capacity developed new or changed skin breakdowns, documented on SBAR forms, but their records lacked evidence of the required 72-hour, every-shift monitoring. A treatment nurse reported that she only completed weekly skin progress notes unless conditions worsened and believed there was no requirement for 72-hour, every-shift documentation for skin-related changes, while an RN acknowledged the policy but stated that licensed nurses were not expected to complete these monitoring notes because treatment nurses were viewed as responsible for treatment and monitoring.
The facility failed to clean and sanitize the ice machine according to the manufacturer's instructions, risking illness from contaminated ice. The Maintenance Director admitted to not mixing descaling and sanitizing solutions correctly, affecting all residents receiving food prepared in the kitchen.
The facility failed to implement control measures to prevent Legionella growth in the water system and did not ensure proper hand hygiene during wound care for a resident. The Maintenance Supervisor could not provide evidence of planned control measures, and an LVN was observed not performing hand hygiene between glove changes during wound care, contrary to facility policy.
The facility failed to accommodate the ethnic food preferences of its residents, particularly those who preferred Korean breakfast. Despite the majority of residents being Korean-speaking, the facility did not provide Korean menus or meals, as confirmed by the DSS and DON. Residents expressed dissatisfaction with the American breakfast options and were not offered Korean alternatives, contrary to the facility's policy for Nutrition Care - Resident Food Preferences.
A resident with a Stage 3 pressure ulcer was found on a low air loss mattress set incorrectly for their weight, despite being unable to communicate comfort levels. The mattress was set for a weight of 175 pounds, while the resident weighed 99 pounds. The LVN and DON confirmed the error, acknowledging the need for the mattress to be set according to the resident's weight.
A resident was observed receiving oxygen at six liters per minute via nasal cannula, contrary to the physician's order for two liters per minute. The facility's policy requires adherence to physician orders, and any changes should be documented and communicated to the physician. The discrepancy was confirmed by the IP and acknowledged by the DON.
A facility's medication error rate was found to be 7.41% due to an LVN administering incorrect supplements to a resident, which did not match the physician's orders. The LVN gave Extra Strength Glucosamine Hcl with MSM and Vision Formula 50+ instead of the prescribed glucosamine-chondroitin and lutein supplements.
Two residents in an LTC facility experienced significant medication errors. One resident received blood pressure medications despite having a systolic blood pressure below the physician-ordered threshold. Another resident was administered carvedilol even though their heart rate was below the ordered parameter. Both errors were confirmed by the DON and involved staff.
A resident refused a laxative medication, but an LVN documented it as administered, resulting in an inaccurate MAR. The DON confirmed that refusals should be documented.
The facility failed to monitor antibiotic use according to McGeer's criteria, leading to inappropriate prescriptions for two residents and lack of verification for another. Antibiotics were prescribed without meeting infection criteria, and there was no documentation of physician notification. The IP confirmed the findings, and the DON acknowledged the issue.
A facility failed to report an abuse allegation to local law enforcement as required by its policy. A resident alleged mistreatment by staff, but the report sent to CDPH did not include notification to law enforcement. The administrator confirmed this oversight.
A facility failed to explain an arbitration agreement to a resident with moderate cognitive impairment who did not understand English. The resident signed the document without comprehension, as it was presented in English by staff who did not speak the resident's language. The Director of Admissions acknowledged the oversight and the need for documents in the resident's language.
Failure to Monitor and Document Change of Condition for New Skin Issues
Penalty
Summary
The facility failed to follow its Change of Condition policy requiring licensed nurses to continue assessment and documentation every shift for 72 hours after a significant change, specifically for residents with new skin issues. The policy, dated 4/2025, states that licensed nurses must contact the physician when there is a significant change of condition, inform family, and document all nursing actions, physician orders, and assessment information, with continued assessment and documentation every shift for 72 hours or until the condition is stable. For three residents who lacked capacity to make medical decisions, SBAR Communication Forms documented new or changed skin conditions: one resident with various small superficial skin breakdowns on the left and right buttocks, another with MASD to the sacrococcyx area, and a third with a small area of skin breakdown on the right perianal fold. However, their medical records did not contain evidence that these changes in condition were monitored and documented every shift for at least 72 hours after the initial observations. During interviews, the Treatment Nurse stated that an SBAR/Change of Condition Report was created whenever a new skin issue was identified, but she believed she was only required to document weekly progress notes on existing skin conditions under treatment, unless the condition worsened or deteriorated. She further stated there was no requirement for licensed nurses to monitor and document every shift for 72 hours after a change of condition related to skin issues. Another RN acknowledged the facility’s policy to monitor residents for at least 72 hours after a change of condition and confirmed that the three residents had change of condition reports related to skin issues, but stated that licensed nurses were not expected to complete monitoring progress notes every shift for 72 hours because treatment nurses were responsible for providing treatment and monitoring as ordered. The Administrator was informed of and acknowledged these findings.
Improper Ice Machine Sanitization
Penalty
Summary
The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's instructions, posing a risk of illness to residents from contaminated ice. During an observation and interview with the Maintenance Director, it was revealed that the facility had one ice machine, and the instructions for cleaning and sanitizing were displayed on an inner panel of the machine. The instructions specified that descaling and sanitizing solutions should be mixed with water. However, the Maintenance Director admitted to not mixing these solutions correctly as per the manufacturer's instructions. This oversight affected all 93 residents who received food prepared in the facility's kitchen, as they were potentially exposed to improperly sanitized ice.
Infection Control Deficiencies in Water Management and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection control practices, specifically in preventing the growth of Legionella bacteria in the water system and ensuring proper hand hygiene during wound care. The facility did not have a comprehensive plan or implemented control measures to prevent the growth of Legionella and other opportunistic pathogens in the water system, as required by CMS guidelines. Although the Maintenance Supervisor stated that a risk assessment was conducted and water testing occurred every six months, there was no evidence of planned and implemented control measures to inhibit microbial growth. Additionally, the facility failed to ensure proper hand hygiene practices during wound care for a resident. The resident, who had a sacrococcyx Stage III wound, was observed receiving wound care from an LVN who did not perform hand hygiene between glove changes. Despite the facility's policy requiring hand hygiene before and after glove use, the LVN changed gloves without washing hands, potentially compromising infection control. Both the LVN and RN assisting in the procedure acknowledged the lapse in hand hygiene during the care process.
Failure to Provide Ethnic Food Preferences
Penalty
Summary
The facility failed to honor and facilitate the residents' preferences and choices for food, specifically for three residents who preferred Korean breakfast. The Dietary Services Supervisor (DSS) confirmed that all residents were served breakfast from the American menu, and Korean menus were not provided in Korean language, despite the majority of residents being Korean-speaking. Resident 22 expressed a preference for Korean breakfast and the ability to read a Korean menu, but was not offered these options. Similarly, Resident 70 stated she would like a Korean breakfast but was not offered one, and Resident 61, who had a diagnosis of unspecified protein-calories malnutrition, expressed dissatisfaction with the American breakfast options provided, preferring Korean food instead. Interviews and observations revealed that the facility did not take into account the ethnic food preferences of its residents, as outlined in their policy for Nutrition Care - Resident Food Preferences. The DSS and the Director of Nursing (DON) acknowledged that a significant portion of the resident population spoke and read primarily Korean, yet the facility did not provide Korean menus or meals. This oversight resulted in residents not being able to choose food items according to their ethnic preferences, as evidenced by Resident 61's actions of modifying her meal with Korean condiments and expressing her preference for Korean food.
Improper Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately according to a resident's weight, which is crucial for pressure ulcer care and prevention. The resident, who weighed 99 pounds, was observed lying on a mattress set to a comfort level corresponding to a weight of 175 pounds. This discrepancy was noted during multiple observations over several days. The facility's policy and procedure for pressure-reducing mattresses, as well as the operating instructions for the mattress system, indicated that the mattress should be set according to the resident's weight. The resident in question had a Stage 3 pressure ulcer and was totally dependent on staff for bed mobility, with documented memory problems and an inability to make medical decisions. Despite these conditions, the mattress was not set to the appropriate level for the resident's weight. The Licensed Vocational Nurse (LVN) confirmed the incorrect setting and acknowledged that the resident could not verbalize comfort levels, necessitating the mattress to be set according to the resident's weight. The Director of Nursing (DON) was informed and acknowledged the findings.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen therapy for a resident, identified as Resident 17, which was observed during a survey. The facility's policy and procedure for oxygen therapy, revised in January 2024, mandates that oxygen should be administered as ordered by the physician. On September 3, 2024, Resident 17 was observed receiving oxygen at six liters per minute via nasal cannula, contrary to the physician's order dated August 24, 2024, which specified oxygen administration at two liters per minute continuously. Additionally, the order allowed for titration up to five liters per minute via mask if the resident's oxygen saturation level fell below 90%. During an interview and concurrent medical record review, the Infection Preventionist (IP) confirmed that Resident 17 was not receiving oxygen as per the physician's order. The IP stated that any increase in oxygen should be documented in the medical record and the physician should be notified. The Director of Nursing (DON) was informed of these findings and acknowledged the discrepancy between the observed oxygen administration and the physician's order.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.41%. This deficiency was identified during a medication administration observation involving an LVN and a resident. The LVN administered medications that did not align with the physician's orders for the resident. Specifically, the LVN gave one tablet of Extra Strength Glucosamine Hcl with MSM and one softgel of Vision Formula 50+ dietary supplement, which were not in accordance with the prescribed glucosamine-chondroitin and lutein supplements. The discrepancy was confirmed when the LVN reviewed the medication labels and compared them to the resident's physician's orders. The physician had ordered glucosamine-chondroitin and lutein supplements, but the LVN administered different supplements that did not match these orders. This failure to administer medications as prescribed had the potential to cause negative outcomes for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 28 and 62, were free from significant medication errors. For Resident 28, the medical record review revealed that on July 19, 2024, the resident was administered amlodipine besylate and losartan potassium-HCTZ despite having a systolic blood pressure (SBP) of 102 mmHg, which was below the physician-ordered parameter of holding the medication for an SBP less than 110 mmHg. The Director of Nursing (DON) confirmed that these medications should not have been administered under these conditions. Similarly, for Resident 62, the medical record review showed that on September 3, 2024, the resident was given carvedilol despite having a heart rate of 57 beats per minute, which was below the ordered parameter of holding the medication for a heart rate less than 60 beats per minute. Both RN 5 and the DON verified that the medication should have been withheld according to the physician's order, acknowledging this as a medication error incident.
Failure to Document Medication Refusal
Penalty
Summary
The facility failed to accurately document a medication refusal for a resident, leading to an inaccurate medication administration record. During an observation, a Licensed Vocational Nurse (LVN) prepared a laxative medication for a resident who refused it because he was leaving for an appointment. Despite the refusal, the LVN documented the medication as administered in the resident's medical record. A subsequent review of the Medication Administration Record (MAR) confirmed the documentation error. The Director of Nursing (DON) later confirmed that medication refusals should be documented as such.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics according to McGeer's criteria for infection in two residents and did not verify if another resident's condition met the criteria. Specifically, Resident 24 and Resident 73 were prescribed antibiotics without meeting the McGeer's criteria for infection. Resident 24 was given a triple antibiotic ointment for an open blister on the leg, and Resident 73 was prescribed a triple antibiotic ointment for a skin tear in the occipital area. In both cases, the symptoms did not align with the criteria for infection, and there was no documentation of physician notification regarding the inappropriate use of antibiotics. Additionally, Resident 29 was prescribed Amoxicillin for swelling and tenderness in the right lower gum, but the facility did not document whether the condition met McGeer's criteria for infection. The Infection Preventionist (IP) confirmed these findings and acknowledged the lack of documentation and follow-up with the physician. The Director of Nursing (DON) was informed and acknowledged the findings as well. These failures had the potential to lead to the use of antibiotics when not indicated, increasing the risk of developing antibiotic-resistant bacteria.
Failure to Report Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This deficiency occurred when the facility did not report an abuse allegation to the local law enforcement for a resident who alleged mistreatment. The facility's Abuse and Neglect Prevention Management policy, revised in August 2018, mandates that all allegations of abuse or mistreatment be reported per state law, including to local law enforcement. On September 3, 2024, a resident alleged that three staff members were mean and rough with her. The facility's administrator was informed of these allegations, and a report was faxed to the California Department of Public Health (CDPH). However, the report did not indicate that local law enforcement was notified. The administrator confirmed that the facility did not notify local law enforcement of the abuse allegation.
Failure to Explain Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to ensure that the arbitration agreement was properly explained to a resident, identified as Resident 12, who had moderate cognitive impairment and did not understand English. The facility's policy required that the arbitration agreement be explained in a form, manner, and language that the resident and their representative could understand. However, this was not adhered to in the case of Resident 12. The resident's medical records indicated a BIMS score of 9, suggesting moderate cognitive impairment, and her Facesheet listed her son and three daughters as responsible parties. During an interview, Resident 12 confirmed that she signed the arbitration agreement but stated that she did not understand the document as it was presented in English, a language she did not know. The Director of Admissions acknowledged that the front desk staff, who did not speak Korean, presented the document to Resident 12. The Director also admitted that Resident 12 was not fully alert at the time of signing and that the facility should have provided the arbitration agreement in Korean to ensure comprehension by Korean-speaking residents and their families.
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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 Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrace View Care Center | 0 mi | — | 28 | 0 |
| The Pavilion At Sunny Hills | 0 mi | — | 7 | 0 |
| St Elizabeth Healthcare Center | 0.4 mi | — | 25 | 0 |
| Park Vista At Morningside | 1.1 mi | — | 21 | 0 |
| St. Catherine Healthcare | 1.7 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.