The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited March 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
Greenfield Care Center of Fillmore, LLC
Fillmore, CA · Medicare-certified · 99 beds
In good standing
For-profitChain member
5 of 5 overall
Greenfield Care Center of Fillmore, LLC has an overall 5-star rating, with 4 stars for health inspections and staffing and 5 stars for quality measures. It reports nurse staffing above the federal benchmark (5.30 vs. 4.1 hours per resident per day), with $0 in fines over the last 24 months; recent inspection citations included accident hazards/supervision, care planning, and professional standards of quality.
Facility ratings
Health inspections
Staffing
5.3013 hrs/resident/day
Quality measures
Last inspection: March 20, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 5.3013.
Staffing detail
- Registered nurses
- 0.97
- Licensed practical nurses
- 1.46
- Nurse aides
- 2.87
- Weekend nursing
- 4.55
Hours per resident per day.
Total staff turnover: 31%
Registered nurse turnover: 36%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
30.8%23.7%Improving
Residents with a fall causing major injury
1.8%1.7%No change
Residents with pressure ulcers (bedsores)
9.8%9.8%No change
Residents with a urinary tract infection
1.9%1.8%No change
Residents who lost too much weight
13.5%1.9%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
14.6%17.5%Worsening
Residents whose ability to walk got worse
—9.8%—
Long-stay residents on antianxiety or sleep medication
35.8%25.5%Improving
Short-stay residents newly given an antipsychotic
0%3.6%Worsening
Residents with a long-term catheter
4.8%0%Improving
Residents with new or worsening incontinence
22.3%17%Improving
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—100%—
Short-stay residents given the pneumonia vaccine
100%100%No change
What the inspectors found
The nursing home failed to develop and carry out a complete care plan that met each resident’s needs with clear steps and timelines. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 656 — 42 CFR §483.21(b)(1) — S/S: E
The nursing home failed to provide services that met professional standards of quality. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 658 — 42 CFR §483.21(b)(3) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: E
The nursing home failed to keep medication mistakes below the allowed level. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 759 — 42 CFR §483.45(f)(1) — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 9 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 11 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $8,018 in total fines.
- $8,018
Federal fine
Mar 13, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of EVA CARE GROUP · 9 homes · 3.3 stars avg
- Occupancy
- 65.9 residents on an average day (67% of 99 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 49 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.