Cycle 1
Health 2025-12-05 · Fire 2025-12-05
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Downey, CA
Brookfield Healthcare Center
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
9300 Telegraph Road, Downey, CA
(562) 869-2567
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1971-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,098
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.48
Baseline 22.24% · Performance 18.61% · Measure score 6.48 · Achievement 6.10 · Improvement 6.48
Healthcare-associated infections
1.1
Baseline 9.18% · Performance 8.51% · Measure score 1.1 · Achievement 0 · Improvement 1.1
Total nurse turnover
6.26
Baseline 45.45% · Performance 38.09% · Measure score 6.26 · Achievement 6.26 · Improvement 3.07
Adjusted total nurse staffing
1.13
Baseline 3.33 hours · Performance 3.40 hours · Measure score 1.13 · Achievement 1.13 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 263 · Observed rate 11.79% · Lower 95% interval 8.53% |
| Discharge to community | 46.1% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 239 · Observed rate 40.17% · Lower 95% interval 40.35% |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 212 · Denominator 214 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 214 |
| Discharge self-care score | 42.14% |
53.69%
11.5 pts worse
|
Numerator 59 · Denominator 140 |
| Discharge mobility score | 35.71% |
50.94%
15.2 pts worse
|
Numerator 50 · Denominator 140 |
| Pressure ulcers or injuries, new or worsened | 0.47% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 214 · Adjusted rate 0.34% |
| Healthcare-associated infections requiring hospitalization | 8.51% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 168 · Observed rate 10.71% · Lower 95% interval 6.03% |
| Staff COVID-19 vaccination coverage | 19.26% |
8.2%
11.1 pts better
|
Numerator 26 · Denominator 135 |
| Staff flu vaccination coverage | 43.93% |
42%
1.9 pts better
|
Numerator 76 · Denominator 173 |
| Discharge function score | 44.29% |
56.45%
12.2 pts worse
|
Numerator 62 · Denominator 140 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | 98.97% |
96.28%
2.7 pts better
|
Numerator 96 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 35 · Denominator 105 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 4.3 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
98.2%
0.4 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
1.6%
0.2 pts worse
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.1% |
6.8%
5.3 pts worse
|
11.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.5% · Q3 12.8% · Q4 16.7% · 4Q avg 12.1% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
13.7%
2.8 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 14.3% · Q3 18.6% · Q4 20.0% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
14.2%
9.4 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.1% · Q3 9.1% · Q4 2.9% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.0% |
11.0%
2 pts worse
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
10.7%
9.6 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 16.7% · Q3 16.7% · Q4 27.6% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.0%
About the same
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.2% |
10.9%
3.3 pts worse
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 5.4% · Q3 25.0% · Q4 14.2% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.7%
2.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.0%
4.1 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.7% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.2%
3.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.6% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
93.2%
3.7 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
23.2%
0.3 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 26.3% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-18 · Fire 2024-10-18
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-10-13 · Fire 2023-10-13
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-19
D · Potential for more than minimal harm
2024-10-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-10-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-10-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-10-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-16
D · Potential for more than minimal harm
2023-10-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-10-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-08
E · Potential for more than minimal harm
2024-10-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-07-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-21
G · Actual harm
2023-10-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-08-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-17
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare Central LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Frischer, Alan
Operational/Managerial Control · Individual
Howell, David
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Kim, Jesse
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Riviera Healthcare Center
Pico Rivera, CA
2-star overall rating with 2-star inspections with $9,110 in total fines with 18 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Colonial Gardens Nursing Home
Pico Rivera, CA
1-star overall rating with 1-star inspections with $44,463 in total fines with 40 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Villa Del Rio Gardens
Bell Gardens, CA
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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