Rose Villa Health Care Center

Name: Rose Villa Health Care Center
Address: 9028 ROSE STREET, Bellflower, CA, 90706, US
Telephone: 5629254252

9028 Rose Street, Bellflower, CA 90706 · Los Angeles County · 53 certified beds · avg 49 residents/day · certified since Nov 1, 1971

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

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.60

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

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.

All citations in the current public record (50)

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
Feb 13, 2026	E · Potential for harm, repeated	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Feb 13, 2026	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint
Feb 13, 2026	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. · from a complaint
Feb 13, 2026	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jan 16, 2026	E · Potential for harm, repeated	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
Nov 26, 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. · from a complaint
Apr 24, 2025	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 24, 2025	E · Potential for harm, repeated	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.
Apr 24, 2025	E · Potential for harm, repeated	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Apr 24, 2025	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Apr 24, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Apr 24, 2025	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.
Apr 24, 2025	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 24, 2025	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.
Apr 24, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 24, 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.
Apr 7, 2024	E · Potential for harm, repeated	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.
Apr 7, 2024	E · Potential for harm, repeated	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Apr 7, 2024	E · Potential for harm, repeated	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.
Apr 7, 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.
Apr 7, 2024	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 7, 2024	E · Potential for harm, repeated	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.
Apr 7, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 7, 2024	D · Potential for harm, one-off	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Apr 7, 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.
Apr 7, 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.
Apr 7, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Apr 7, 2024	D · Potential for harm, one-off	The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
Apr 7, 2024	D · Potential for harm, one-off	The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them.
Apr 7, 2024	D · Potential for harm, one-off	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Apr 7, 2024	D · Potential for harm, one-off	The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Apr 7, 2024	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Apr 7, 2024	D · Potential for harm, one-off	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Mar 5, 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. · from a complaint
Oct 13, 2023	D · Potential for harm, one-off	The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint
Apr 8, 2022	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 8, 2022	E · Potential for harm, repeated	The facility did not provide enough space and equipment to meet each resident's needs.
Apr 8, 2022	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.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Apr 8, 2022	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.
Apr 8, 2022	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.
Apr 8, 2022	D · Potential for harm, one-off	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.
Apr 8, 2022	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.
Apr 8, 2022	D · Potential for harm, one-off	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.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Apr 8, 2022	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (17 → 10).

Year	Citations	Worst severity that year
2022	15	E
2023	1	D
2024	18	E
2025	11	E
2026	5	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)	3.60	4.31	3.95	bottom 15% in California; bottom 42% in the U.S.
Registered Nurse hours	0.58	0.61	0.69	top 34% in California; bottom 50% in the U.S.
Weekend total nurse staffing	3.15	3.90	3.50	bottom 9% in California; bottom 39% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.31	0.51	0.48	bottom 37% in California; bottom 34% in the U.S.
Total nursing staff turnover (%)	32.7	36.7	45.8	top 39% in California; top 19% in the U.S.
RN turnover (%)	41.7	38.1	42.9	bottom 41% in California; top 50% 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 4.07, RN 0.66, weekend 3.56. Staffing rating: 3/5.

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: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Flagstone Healthcare South LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	01/30/2006
The Ensign Group INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/30/2006
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	01/30/2006
Burnam, Soon	Individual	ADP of the SNF	NOT APPLICABLE	07/07/2025
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
Ctr Partnership LP	Organization	ADP of the SNF	NOT APPLICABLE	06/01/2003
Ensign Bellflower LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/01/2003
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	09/14/2011
Howell, David	Individual	Managing Control - Governing Body	NOT APPLICABLE	06/05/2013
Howell, David	Individual	Operational/Managerial Control	NOT APPLICABLE	06/05/2013
Howell, David	Individual	ADP of the SNF	NOT APPLICABLE	07/07/2025
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Pole, Shivanand	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/01/2024
Pole, Shivanand	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2024
Pole, Shivanand	Individual	ADP of the SNF	NOT APPLICABLE	07/07/2025
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	07/07/2025
Willits, Adam	Individual	Corporate Director	NOT APPLICABLE	04/29/2019

Questions to ask on your visit

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

"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"How do you keep residents' medical records accurate, complete, and secure?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
"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
Bellflower Post Acute	0.7 mi	Bellflower, CA	★★☆☆☆	2/5
Bay Vista Healthcare & Wellness Centre, LP	0.7 mi	Long Beach, CA	★★☆☆☆	2/5
Cerritos Vista Healthcare Center	1.1 mi	Bellflower, CA	★☆☆☆☆	1/5
Sunset Villa Post Acute	1.2 mi	Long Beach, CA	★★☆☆☆	1/5
Villa Del Sol Post Acute	1.4 mi	Bellflower, CA	★★☆☆☆	2/5
La Paz Geropsychiatric Center	1.5 mi	Paramount, CA	★★☆☆☆	1/5	abuse
Paramount Convalescent Hosp.	2.4 mi	Paramount, CA	★★★☆☆	2/5
Meadow Creek Post-Acute	2.7 mi	Paramount, CA	★☆☆☆☆	1/5
Artesia Christian Home INC.	2.9 mi	Artesia, CA	★☆☆☆☆	1/5
The Springs Post-Acute	3.0 mi	Norwalk, CA	★☆☆☆☆	1/5
North Long Beach Post Acute	3.1 mi	Long Beach, CA	★☆☆☆☆	1/5
Artesia Palms Care Center	3.5 mi	Artesia, CA	★☆☆☆☆	2/5	abuse

Compare this facility with the 3 closest →

All facilities in Bellflower →

Facility data as of CMS processing date 2026-08-01. CCN 056104.

The Care File

Visit checklist — Rose Villa Health Care Center

9028 Rose Street, Bellflower, CA 90706 · 5629254252

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

Questions for the administrator:

☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
☐ "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 056104 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)