Map showing the location of ROSE VILLA HEALTH CARE CENTER in BELLFLOWER, California
9028 ROSE STREET, BELLFLOWER, CA, 90706

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaAbove only 37% of peers1,154 rated homes · average 3.2★
  • Los Angeles CountyAbove 57% of peers368 rated homes · average 2.5★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs CA avg
  • StaffingCan add or remove a star3★−0.1 vs CA avg
  • Quality measuresCan add or remove a star3★−1.1 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 44% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 9% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.70hrsAbove only 5% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.89hrsAbove 85% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better38%Above only 47% of peersCA avg38%RN turnover33%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 45% of peersCA avg$26,970Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
45citations
6inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Nov 26, 2025most recent

Citations by monthApr 2022 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 26, 20251 citationCycle 1worst E · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Dec 22, 2025
Apr 24, 202510 citationsCycle 1worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 23, 2025
  2. F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected May 23, 2025
  3. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 23, 2025
  4. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected May 23, 2025
  5. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected May 23, 2025
  6. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected May 23, 2025
  7. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 23, 2025
  8. F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 23, 2025
  9. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 23, 2025
  10. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 23, 2025
Apr 7, 202417 citationsCycle 2worst E · no actual harm
  1. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected May 7, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 7, 2024
  3. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected May 7, 2024
  4. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 7, 2024
  5. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected May 7, 2024
  6. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 7, 2024
  7. F688Provide 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.Quality of Life and CareE · patternCorrected May 7, 2024
  8. F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareD · isolatedCorrected May 7, 2024
  9. F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician ServicesD · isolatedCorrected May 7, 2024
  10. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected May 7, 2024
  11. F758Implement 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.Pharmacy ServiceE · patternCorrected May 7, 2024
  12. F761Ensure 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.Pharmacy ServiceE · patternCorrected May 7, 2024
  13. F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.AdministrationD · isolatedCorrected May 7, 2024
  14. F803Ensure 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.Nutrition and DietaryD · isolatedCorrected May 7, 2024
  15. F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationD · isolatedCorrected May 7, 2024
  16. 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.Resident RightsD · isolatedCorrected May 7, 2024
  17. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected May 7, 2024
Mar 5, 20241 citationCycle 2worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 29, 2024
Oct 13, 20231 citationCycle 3worst D · no actual harm
  1. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Nov 6, 2023
Apr 8, 202215 citationsCycle 3worst E · no actual harm
  1. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected May 6, 2022
  2. F688Provide 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.Quality of Life and CareD · isolatedCorrected May 6, 2022
  3. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected May 6, 2022
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 6, 2022
  5. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 6, 2022
  6. F758Implement 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.Pharmacy ServiceE · patternCorrected May 6, 2022
  7. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected May 6, 2022
  8. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 6, 2022
  9. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected May 6, 2022
  10. F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected May 6, 2022
  11. F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected May 6, 2022
  12. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected May 6, 2022
  13. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected May 6, 2022
  14. F907Provide enough space and equipment to meet each resident's needsEnvironmentalE · patternCorrected May 6, 2022
  15. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 6, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.70hrsAbove only 5% of peers−0.81 vs CA avg
  • Registered nursesRN hours only0.89hrsAbove 85% of peers+0.24 vs CA avg
  • Licensed practical nursesLPN hours1.05hrs
  • Nurse aidesCNA hours1.75hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.35hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better38%Above only 47% of peersCA avg 38%
  • RN turnoverRegistered nurses only33%Not ranked by CMS
  • Administrators who leftIn the past year
  • Occupancy53 certified beds · ~50 residents a day95%Above 80% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $26,970CA avg in fines
Above only 45% of peersFewer fines than 45% of rated homes in California

Actions on record

No fines or payment denialsNothing on record in the current reporting window. California facilities average 1.3 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Flagstone Healthcare South LLC
Indirect owners (5%+)
  • The Ensign Group INC
Operational or managerial control
  • David Howell
Corporate officers
  • Soon Burnam
  • Adam Willits
Managing employees
  • David Howell

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 056104 · 9028 ROSE STREET, BELLFLOWER, CA, 90706.
  • Percentiles compare this facility with every rated nursing home in California and Los Angeles County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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