Brookfield Healthcare Center

Name: Brookfield Healthcare Center
Address: 9300 TELEGRAPH ROAD, Downey, CA, 90240, US
Telephone: 5628692567

9300 Telegraph Road, Downey, CA 90240 · Los Angeles County · 70 certified beds · avg 63 residents/day · certified since Sep 1, 1971

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.49

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Oct 13, 2023 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 9, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (27)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Dec 5, 2025	E · Potential for harm, repeated	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 24, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Jul 24, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Oct 18, 2024	E · Potential for harm, repeated	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 31, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Oct 13, 2023	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 13, 2023	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Oct 13, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 13, 2023	E · Potential for harm, repeated	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Oct 13, 2023	D · Potential for harm, one-off	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Oct 13, 2023	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Oct 13, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Aug 1, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (10 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2023	8	1	G ▲
2024	11	0	E
2025	8	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.49	4.31	3.95	bottom 10% in California; bottom 36% in the U.S.
Registered Nurse hours	0.80	0.61	0.69	top 17% in California; top 27% in the U.S.
Weekend total nurse staffing	3.22	3.90	3.50	bottom 12% in California; bottom 43% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.73	0.51	0.48	top 14% in California; top 14% in the U.S.
Total nursing staff turnover (%)	36.4	36.7	45.8	top 50% in California; top 27% in the U.S.
RN turnover (%)	22.2	38.1	42.9	top 23% in California; top 17% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.02, RN 0.93, weekend 3.70. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/30/2006
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	01/30/2006
Caretrust GP LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/01/2003
Caretrust Reit INC	Organization	ADP of the SNF	NOT APPLICABLE	06/01/2003
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	05/09/2023
Frischer, Alan	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/01/2024
Frischer, Alan	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2024
Frischer, Alan	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2024
Howell, David	Individual	Managing Control - Governing Body	NOT APPLICABLE	06/24/2012
Howell, David	Individual	Operational/Managerial Control	NOT APPLICABLE	06/24/2012
Howell, David	Individual	ADP of the SNF	NOT APPLICABLE	06/24/2012
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Kim, Jesse	Individual	Corporate Officer	NOT APPLICABLE	05/09/2023
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	07/03/2025
The Ensign Group INC	Organization	ADP of the SNF	NOT APPLICABLE	05/09/2023
Trousdale Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/01/2003

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Riviera Healthcare Center	0.8 mi	Pico Rivera, CA	★☆☆☆☆	2/5
Colonial Gardens Nursing Home	1.6 mi	Pico Rivera, CA	★☆☆☆☆	1/5
Villa Del Rio Gardens	2.0 mi	Bell Gardens, CA	★★☆☆☆	3/5
Southland	2.1 mi	Norwalk, CA	★☆☆☆☆	1/5
Downey Community Health Center	2.2 mi	Downey, CA	★★☆☆☆	2/5
Socal Post-Acute Care	2.3 mi	Whittier, CA	★★★☆☆	3/5
El Rancho Vista Health Care Center	2.5 mi	Pico Rivera, CA	★★★★☆	3/5
Lakewood Healthcare Center	2.7 mi	Downey, CA	★☆☆☆☆	1/5	abuseSFF
Intercommunity Healthcare & Rehabilitation Center	2.8 mi	Norwalk, CA	★★☆☆☆	2/5
Norwalk Skilled Nursing & Wellness Centre, LLC	2.8 mi	Norwalk, CA	★☆☆☆☆	1/5
The Orchard - Post Acute Care	3.0 mi	Whittier, CA	★★☆☆☆	2/5
Presbyterian Intercomm Hosp DP/SNF	3.0 mi	Whittier, CA	★★★★★	5/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 056014.

The Care File

Visit checklist — Brookfield Healthcare Center

9300 Telegraph Road, Downey, CA 90240 · 5628692567

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Most serious findings on record:

▲ Oct 13, 2023 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 056014 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)