Inspection Reports for
Greenfield Care Center of Fullerton
330 W Bastanchury Rd, Fullerton, CA 92835, United States, CA, 92835
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to providing appropriate treatment and services to residents diagnosed with dementia.
Findings
The facility failed to obtain the neurologist's progress notes and develop a dementia care plan for one sampled resident (Resident 24) diagnosed with dementia, potentially impacting the resident's receipt of appropriate treatment and services. The facility did not implement or develop a care plan specific to the resident's dementia and failed to document attempts to obtain neurologist progress notes.
Deficiencies (1)
Failure to provide appropriate treatment and services to a resident diagnosed with dementia, including failure to obtain neurologist progress notes and develop a dementia care plan.
Report Facts
Residents affected: 1
Medication administration dates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Interviewed and verified findings related to Resident 24's dementia care plan absence |
| DON | Director of Nursing | Interviewed and acknowledged findings regarding failure to obtain neurologist progress notes and develop dementia care plan |
Inspection Report
Routine
Deficiencies: 12
Date: Sep 11, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including care planning, dialysis services, medication administration, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to implement and revise comprehensive care plans, improper dialysis care and medication administration, inaccurate medical record documentation, inadequate infection control practices, and food safety violations. Several residents' care plans were not updated or followed, medications were not administered as ordered, and infection prevention protocols were not consistently followed.
Deficiencies (12)
Failed to implement the comprehensive care plan for Resident 91's AV shunt, including obtaining blood pressure on the wrong arm.
Failed to revise Resident 43's long-term care plan to reflect a recent fall.
Failed to provide appropriate pressure ulcer care for Resident 2, including improper wound treatment application.
Failed to ensure environment free from accident hazards by inaccurate post-fall risk assessment for Resident 43.
Failed to provide necessary dialysis care and services for Residents 10 and 91, including failure to follow up on lab results and improper blood pressure measurement on AV shunt arm.
Failed to provide appropriate dementia care for Resident 24, including lack of neurologist progress notes and care plan.
Failed to ensure pharmaceutical services met residents' needs, including inaccurate medication administration documentation and untimely medication administration for Residents 10 and 91.
Medication error rate was 8%, exceeding the 5% threshold, with errors in administration of eye drops and Creon medication.
Failed to ensure proper storage and disposal of medications, including opened single-use collagen powder and expired supplies.
Failed to follow food safety and sanitation guidelines, including storing a blender wet and using a damaged serving scoop.
Failed to maintain accurate medical records for Resident 91, documenting blood sugar measurements while resident was at dialysis center.
Failed to implement infection prevention and control practices, including improper hand hygiene by kitchen aide and staff, and wound care practices that risk contamination.
Report Facts
Medication error rate: 8
Medication error threshold: 5
Residents sampled: 21
Dialysis treatments frequency: 2
Deficiency count: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in findings related to improper blood pressure measurement on AV shunt arm and medication administration errors |
| RN 1 | Registered Nurse | Named in findings related to medication administration errors and care plan review |
| LVN 3 | Licensed Vocational Nurse | Named in wound care observation and infection control findings |
| RN 3 | Registered Nurse | Named in medication administration and medical record documentation findings |
| RN 4 | Registered Nurse | Named in medication administration observation and interview |
| RN 5 | Registered Nurse | Named in medication cart inspection and medication storage findings |
| RN 6 | Registered Nurse | Named in medication storage room inspection |
| RN 2 | Registered Nurse | Named in dementia care plan and fall risk assessment findings |
| DON | Director of Nursing | Named in multiple interviews acknowledging findings |
| ADON | Assistant Director of Nursing | Named in interviews related to dialysis lab follow-up and medication administration |
| Administrator | Facility Administrator | Named in interviews acknowledging findings |
| Kitchen Aide 1 | Kitchen Aide | Named in infection control hand hygiene observation |
| DSS | Dietary Services Supervisor | Named in food safety and sanitation observations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 6, 2024
Visit Reason
The inspection was conducted due to an abuse allegation made by Resident 47, specifically to investigate the facility's failure to report suspected abuse to local law enforcement as required by policy and law.
Complaint Details
The complaint investigation was substantiated as the facility did not notify local law enforcement of the abuse allegation involving Resident 47.
Findings
The facility failed to implement its policy and procedure for timely reporting suspected abuse to local law enforcement for one resident's abuse allegation, potentially delaying law enforcement response.
Deficiencies (1)
Failure to report an abuse allegation to local law enforcement for Resident 47 as required by facility policy and state law.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and verified the facility did not notify local law enforcement of the abuse allegation. |
Inspection Report
Routine
Census: 93
Deficiencies: 10
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, abuse reporting, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate residents' ethnic food preferences, failure to report abuse allegations to law enforcement, improper pressure ulcer care, oxygen therapy not administered as ordered, medication errors exceeding 5%, improper cleaning of ice machine, inaccurate medication refusal documentation, failure to explain arbitration agreements in resident's language, inadequate infection control practices including Legionella water management and hand hygiene, and deficiencies in antibiotic stewardship monitoring.
Deficiencies (10)
Failed to facilitate residents' preferences and choices for food, specifically Korean breakfast and menu language for three residents.
Failed to report an abuse allegation to local law enforcement for one resident.
Low air loss mattress not set appropriately according to resident's weight for pressure ulcer care.
Oxygen therapy not administered as per physician's order for one resident.
Medication error rate was 7.41%, exceeding the 5% threshold, including incorrect medication administration and failure to hold medications as ordered.
Ice machine was not cleaned and sanitized according to manufacturer's instructions.
Failed to document medication refusal accurately for one resident.
Arbitration agreement was not explained in a language the resident understood, posing risk to resident rights.
Failed to maintain infection control practices including Legionella water management and hand hygiene during wound care.
Failed to monitor and address antibiotic use according to McGeer's criteria for infection in multiple residents.
Report Facts
Medication error rate: 7.41
Residents affected by food preference deficiency: 3
Residents affected by abuse reporting deficiency: 1
Residents affected by pressure ulcer mattress setting deficiency: 1
Residents affected by oxygen therapy deficiency: 1
Residents affected by medication administration errors: 3
Residents affected by medication refusal documentation deficiency: 1
Residents affected by arbitration agreement deficiency: 1
Residents affected by infection control deficiencies: 1
Residents affected by antibiotic stewardship deficiencies: 3
Residents receiving meals prepared by kitchen: 91
Residents speaking and reading primarily Korean: 89
Resident 486 weight: 99
Low air loss mattress comfort level observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Named in medication administration error finding involving Resident 63 and medication refusal documentation for Resident 83 | |
| LVN 2 | Named in infection control deficiency for failure to perform hand hygiene between glove changes during wound care for Resident 486 | |
| RN 3 | Interviewed regarding residents' food preferences | |
| RN 5 | Observed assisting LVN 2 during wound care and interviewed about hand hygiene | |
| Administrator | Interviewed regarding abuse reporting and acknowledged findings | |
| DON | Director of Nursing | Interviewed and acknowledged multiple findings including oxygen therapy, medication errors, infection control, and antibiotic stewardship |
| DSS | Dietary Services Supervisor interviewed about food preferences and menu language | |
| Maintenance Director | Interviewed about ice machine cleaning and sanitizing | |
| Maintenance Supervisor | Interviewed about Legionella water management program | |
| IP | Infection Preventionist | Interviewed about oxygen therapy and antibiotic stewardship findings |
| Director of Admissions | Interviewed regarding arbitration agreement explanation to Resident 12 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 29, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory standards related to resident care, safety, medication administration, food safety, infection control, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to keep bed remote controls and call lights within reach of residents, inadequate protection of residents' personal property, untimely medication administration, food safety and sanitation violations, improper garbage disposal, and lapses in infection prevention and control practices including hand hygiene and lack of Legionella risk assessment documentation.
Deficiencies (6)
Bed remote control and call light were not kept within reach for one resident, impacting ability to call for assistance.
Facility failed to provide reasonable care for protection of resident's personal property from loss or theft.
Medication (polyethylene glycol) was not administered in a timely manner.
Food safety and sanitation requirements were not met including unlabeled/undated foods, failure to air dry equipment, and worn kitchen utensils.
Garbage dumpsters lids were left open, risking pest infestation.
Failure to implement infection prevention and control program including inadequate hand hygiene by staff during wound care and medication administration, lack of Legionella risk assessment and testing protocols, and absence of proper disposal bins in isolation room.
Report Facts
Residents sampled: 19
Residents sampled: 19
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 90
Total residents: 92
Residents affected: 39
Isolation duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Verified bed remote and call light not within reach; failed to perform hand hygiene during wound care |
| SSD | Social Services Director | Involved in resident property transfer and lock issue |
| Maintenance Director | Decided against allowing resident to use chain and padlock on cabinet | |
| LVN 2 | Licensed Vocational Nurse | Withheld medication and acknowledged delay in administration |
| DSS | Dietary Services Supervisor | Verified food safety and sanitation deficiencies and garbage dumpster lids open |
| LVN 1 | Licensed Vocational Nurse | Failed to perform hand hygiene during wound care |
| LVN 6 | Licensed Vocational Nurse | Failed to perform hand hygiene during medication administration |
| LVN 5 | Licensed Vocational Nurse | Failed to perform hand hygiene before administering eye drops |
| DON | Director of Nursing | Verified hand hygiene deficiencies |
| Maintenance Supervisor | Verified no Legionella risk assessment or testing protocols | |
| CNA 2 | Certified Nursing Assistant | Verified lack of trash bin and laundry hamper in isolation room |
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