Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
4’23
36’24
45’25
35’26
120 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 21, 2026 | D · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Jul 9, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 9, 2026 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jul 9, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jun 10, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Jun 10, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Apr 15, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 15, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Feb 9, 2026 | D · potential | Give the resident's representative the ability to exercise the resident's rights. | Routine |
| Feb 9, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Feb 9, 2026 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Feb 9, 2026 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Feb 9, 2026 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Feb 9, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 9, 2026 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Feb 9, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Feb 9, 2026 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Feb 9, 2026 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Feb 9, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 9, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Feb 9, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 9, 2026 | D · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Feb 9, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 9, 2026 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Feb 9, 2026 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Feb 9, 2026 | D · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Feb 9, 2026 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Feb 9, 2026 | D · potential | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Routine |
| Feb 9, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 9, 2026 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Feb 9, 2026 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Feb 3, 2026 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Feb 3, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Feb 3, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 3, 2026 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Complaint |
| Nov 18, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Nov 18, 2025 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Complaint |
| Nov 13, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Nov 13, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 21, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jul 21, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Jul 21, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| May 29, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 17, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 7, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 13, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Feb 13, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Feb 13, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Feb 13, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Feb 13, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 13, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Feb 13, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Feb 13, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Feb 13, 2025 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Feb 13, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 13, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Feb 13, 2025 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Feb 13, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Feb 13, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 13, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 13, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Feb 13, 2025 | E · potential | 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. | Routine |
| Feb 13, 2025 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Feb 13, 2025 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Feb 13, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Feb 13, 2025 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Feb 13, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 13, 2025 | F · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Feb 13, 2025 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 13, 2025 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Feb 6, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 6, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 6, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 23, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jan 23, 2025 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jan 23, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 2, 2025 | G · harm | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jan 2, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jan 2, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 2, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 4, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Nov 20, 2024 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Nov 20, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Nov 20, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Nov 20, 2024 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Complaint |
| Oct 29, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Oct 2, 2024 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Oct 2, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Oct 2, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Oct 2, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Complaint |
| Aug 23, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 23, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 23, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jul 10, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 23, 2024 | D · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Complaint |
| May 19, 2024 | J · harm | Protect each resident from the wrongful use of the resident's belongings or money. | Complaint |
| Apr 2, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 2, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 27, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 27, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Feb 23, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Feb 23, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Feb 23, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 23, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Feb 23, 2024 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Routine |
| Feb 23, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 23, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Feb 23, 2024 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Feb 23, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 23, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 23, 2024 | E · potential | 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. | Routine |
| Feb 23, 2024 | F · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Feb 23, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 23, 2024 | F · potential | Dispose of garbage and refuse properly. | Routine |
| Feb 23, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 23, 2024 | F · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Nov 22, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 30, 2023 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Oct 28, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Oct 12, 2023 | D · potential | Protect each resident from the wrongful use of the resident's belongings or money. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Santa Fe Heights Healthcare Center, LLC
2309 N Santa Fe Ave, Compton, CA 90222 · (310) 639-8111
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555732
- Certified beds
- 99
- Legal owner
- Santa Fe Heights Healthcare Center LLC
- Part of
- Crystal Solorzano
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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