The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited October 2023 — isolated incident, actual harm.
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F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
BROOKFIELD HEALTHCARE CENTER
DOWNEY, CA · Medicare-certified · 70 beds
In good standing
For-profitChain member
5 of 5 overall
Brookfield Healthcare Center in Downey has an overall 5-star rating, with 4 stars for health inspections and staffing and 5 stars for quality measures. It reported 4.20 nurse staffing hours per resident per day versus the 4.1 federal benchmark, had $0 in fines over the last 24 months, and recent inspection citations included accident hazards, medication errors, and unnecessary drugs.
Facility ratings
Health inspections
Staffing
4.1956 hrs/resident/day
Quality measures
Last inspection: December 5, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.1956.
Staffing detail
- Registered nurses
- 1.01
- Licensed practical nurses
- 0.75
- Nurse aides
- 2.44
- Weekend nursing
- 3.79
Hours per resident per day.
Total staff turnover: 31%
Registered nurse turnover: 20%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
2.5%Improving
Residents with a fall causing major injury
1.2%Improving
Residents with pressure ulcers (bedsores)
1.4%Improving
Residents with a urinary tract infection
0.7%Steady
Residents who lost too much weight
0%Steady
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
17.1%Improving
Residents whose ability to walk got worse
8.8%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
15.2%Improving
Short-stay residents newly given an antipsychotic
0%Steady
Residents with a long-term catheter
1%Improving
Residents with new or worsening incontinence
11.8%Improving
Residents with depressive symptoms
10.7%Improving
Long-stay residents given the seasonal flu vaccine
97.8%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
96.9%Steady
Short-stay residents given the pneumonia vaccine
99.6%Improving
What the inspectors found
The nursing home failed to ensure residents were free from significant medication errors. Cited December 2025 — limited pattern, potential for harm.
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F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: E
The home failed to ensure residents’ medications were free from unnecessary drugs. Cited October 2024 — limited pattern, potential for harm.
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F-Tag 757 — 42 CFR §483.45(d) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited October 2023 — limited pattern, potential for harm.
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F-Tag 755 — 42 CFR §483.45 — S/S: E
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited October 2023 — limited pattern, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 62 residents on an average day (89% of 70 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 54 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.