Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rowntree Gardens during CMS and state inspections, most recent first.
Unclear psychotropic behavior monitoring led to a deficiency for two residents. One resident received divalproex and escitalopram for dementia with behavioral disturbance and depression, but the LPNs’ documented behaviors were not specific, and the ADON agreed the monitoring was not specific. Another resident received aripiprazole for depression with mood swings, but the behavior monitoring did not match the diagnosis, and staff acknowledged the mismatch.
A resident with a history of CVA and left-sided hemiparesis had orders for a left PRAFO boot when in bed and a left-hand splint for 4 hours daily, but staff did not follow the PRAFO order as written. The resident was observed in bed without the boot, the device was found stored on the bedside drawer, and the RNA stated the boot and hand splint were applied together for 4 to 6 hours instead of the boot being used when the resident was in bed.
Failure to Verify Competency for PureWick Use: The facility did not ensure an LPN had documented competency for all aspects of PureWick care for a resident using the device. Records showed PureWick education and a skills checklist for cleaning, but the LPN stated he was trained on cleaning and application by the IP, and the IP confirmed she did not assess competency on the same day the checklist was signed and had no record of when the application observation occurred.
Failure to document NPI for residents receiving routine psychotropic medications. For one resident with dementia, depression, anxiety, and psychosis, the record showed orders for divalproex and escitalopram, but staff did not document NPI for behaviors such as screaming, confusion, resistance to care, and calling out, even though staff described interventions like TV, music, and activities. For two other residents, the MARs did not show NPI before administration of buspirone, Depakote, quetiapine, bupropion, aripiprazole, and sertraline for behaviors including aggression, crying spells, mood swings, and sadness; staff and the ADON confirmed routine psychotropic meds were being given without documented NPI.
Surveyors found multiple kitchen sanitation and food safety issues, including a dirty stove hood, contaminated refrigerator fans above uncovered juice pitchers, and a can opener with a chipped blade. They also observed diced onions past the use-by date, resident food brought from outside that was not properly labeled or dated, and a food production sink plumbed directly to the main drain without an air gap. The DSS, DSD, and Maintenance Technician verified the findings.
The facility failed to carry out its infection surveillance program as written, because the IP did not initiate McGeer’s criteria for residents with signs and symptoms of infection who were not prescribed antimicrobials. The facility also lacked specific testing protocols and acceptable control ranges in its Legionella water management program. In addition, a CNA did not wear a gown while providing contact care to a resident on EBP for a GT, and hand hygiene was not offered before a resident ate lunch.
Antibiotic Stewardship Program Not Followed: The facility did not follow its P&P for suspected infections and antibiotic orders. An LPN/RN would complete a change of condition assessment and notify the physician when a resident had signs or symptoms of infection, but the McGeer’s criteria form was not initiated until after the physician had already prescribed antibiotics. The IP stated the facility used McGeer’s criteria to determine infection, yet the criteria were not applied before the antibiotic order was given.
A resident with cerebral edema, left-sided weakness, and pain/discomfort was observed lying in bed and stated she was uncomfortable. Her bed repositioning controller was wrapped around the TV and out of her sight and reach. The assigned CNA confirmed the controller should have been placed within reach before leaving the room, and stated the resident required total care and repositioned herself frequently due to pain.
Failure to Follow Care Plan for Nasal Cannula Storage: A resident with COPD and continuous O2 use had a nasal cannula observed lying directly on top of the O2 concentrator instead of being stored properly at the bedside. The resident said she used O2 for breathing and had last used it that morning, and an LVN confirmed the cannula should have been kept in a clean plastic bag for infection control per the care plan.
A resident with pneumonia and acute respiratory failure with hypoxia did not receive a scheduled budesonide neb treatment when the medication was not available from the pharmacy. The MAR and progress notes showed the dose was awaiting delivery, but there was no documentation that the dose was administered or that the MD was notified of the missed medication.
A resident with a history of falls had an incomplete fall risk eval after being found on the floor, with missing VS, pain assessment, and nurse signature. The record also showed inaccurate fall history and med review entries despite the resident taking mirtazapine, and there was no documentation of monitoring for attempts to get out of bed unassisted as listed in the care plan.
Respiratory Care Deficiencies: Two residents receiving O2 therapy had issues with nasal cannula storage, and one resident also lacked a physician order for continuous O2 at 2 L/min via NC. Surveyors observed the cannulas lying directly on an O2 concentrator and a wheelchair, and an LVN confirmed the improper storage and the missing order.
Inadequate pain management was identified for two residents. One resident received morphine for a pain score below the ordered severe-pain range, and another resident’s MAR did not document NPI before acetaminophen was given for knee pain. The facility policy required assessment, documentation, and evaluation of NPI before pain meds were administered.
A resident with a seizure disorder had a levetiracetam order changed from tablet to liquid after refusing the morning dose, but the pharmacy did not deliver the new medication in a timely manner. An LVN also transcribed the order incorrectly as once daily instead of BID, despite the physician ordering the medication for morning and evening administration.
A facility failed to keep accurate medical records for three residents. One resident’s MAR showed a levetiracetam dose as given even though the resident refused it, another resident’s MAR incorrectly recorded 97 crying spells instead of seven, and a third resident’s skin assessments were inconsistent for bruising/discoloration with no physician notification documented when findings changed. The DON, ADON, and an LPN verified the documentation errors.
Care Plan Not Revised for Incontinence Needs: A resident with bladder and bowel incontinence had a care plan that still included an intervention to assess candidacy for B&B retraining or toileting, even though the MDS Coordinator stated the resident was not a candidate. The medical record did not show documentation of an assessment, and the care plan was not revised to remove the outdated intervention.
A facility failed to send required discharge documents to a home health agency, delaying a resident's receipt of necessary care. The resident was discharged with orders for home health services, including RN and PT services, but the discharge team delayed sending the documents for 12 days. The social services director admitted to forgetting to fax the documents until contacted by the resident's family. The director of nursing acknowledged the findings.
A facility failed to conduct necessary entrapment risk assessments for 13 residents using bed side rails, as required by their policies. Observations and interviews revealed that residents with varying cognitive and physical impairments were using side rails without documented assessments, posing potential safety risks. Staff interviews confirmed that measurements specific to each resident's size and weight were not conducted, and the DON acknowledged these deficiencies.
The facility failed to meet food safety and sanitation standards in the kitchen, including improper handwashing, inadequate labeling and dating of food, and poor maintenance of equipment. Staff did not wash hands before donning gloves, and several food items were found unsealed and undated in the freezer. Additionally, kitchen equipment was not properly cleaned or stored, and the ice machine had residue buildup. These issues were acknowledged by the Food Services Director.
The facility failed to conduct entrapment assessments and record measurements during bed inspections for 13 residents using bed rails. Despite policies requiring these assessments, there was no documented evidence of routine inspections to identify potential entrapment areas. An RA admitted to not inspecting or measuring bed dimensions according to residents' size, weight, and height, or when there was a change of bed or mattress, posing risks of entrapment and injury.
A resident with a right arm sling was unable to reach the call light, which was clipped to the bed rail, leading to delayed assistance. The resident, who had fluctuating decision-making capacity, mistakenly used the bed remote as the call light. An LVN confirmed the issue and corrected it, while the DON acknowledged the deficiency.
The facility failed to develop comprehensive care plans for two residents, one requiring an antibiotic for a UTI and another using a PureWick catheter. The absence of care plans addressing these needs was confirmed through staff interviews and observations, revealing a lack of education on infection prevention and control for the catheter user. These deficiencies risked inconsistent and inappropriate care.
A resident developed a Stage 3 pressure ulcer due to the facility's failure to provide high protein snacks as recommended and improper wound care practices. The care plan was not updated to include the RD's recommendation, and an LVN did not use a protective barrier during wound care, exposing the wound to contamination.
The facility failed to provide proper catheter care for two residents, leading to a risk of urinary tract infections. One resident's PureWick collection canister had dry, dark green residue due to improper cleaning and monitoring, while another resident's indwelling urinary catheter drainage bag was found on the floor, contrary to care plan instructions. Staff unfamiliarity with PureWick catheter care and incomplete in-service training contributed to these deficiencies.
A facility failed to maintain appropriate respiratory care for a resident by not changing the storage bag for the Yankauer suction tip weekly as required. The resident, unable to make decisions, had a physician's order for suctioning oral secretions. An LVN confirmed the bag was not changed weekly, which was necessary for infection control. The DON acknowledged the oversight.
The facility failed to maintain an updated Certification of Infection Preventionist Training for the Acting IP and did not ensure nursing staff competency in caring for a resident's PureWick catheter system. The PureWick system was not cleaned according to guidelines, and staff were unfamiliar with its care procedures. The DON, ADON, and Acting IP acknowledged these deficiencies.
A facility failed to accurately document and reconcile the administration of controlled medications for a resident. The Controlled Medication Count Sheet showed hydrocodone/acetaminophen was removed by a nurse, but the MAR lacked documentation of its administration. Interviews with staff confirmed the discrepancy, and the DON acknowledged the issue.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of medications to two residents. An LVN did not follow the facility's policy for eye drop administration for a resident with glaucoma, using more drops than prescribed. Another resident received methenamine hippurate without food, against physician orders. The LVN acknowledged these errors, which were confirmed by the DON.
The facility failed to properly store and label medications, with issues including expired nitroglycerine tablets, improper storage of various medications, and inaccurate glucose monitoring. Additionally, there were missing records in the Medication Room and Refrigerator Temperature Logs, which were acknowledged by the ADON and DON.
A resident was not provided with their preferred chocolate shake during a meal, despite it being listed on their meal ticket. The CNA and RD confirmed the discrepancy, and the DON acknowledged the oversight, indicating a failure to follow the facility's policy on resident food preferences.
The facility failed to provide safe food handling instructions to family members bringing food for residents and did not maintain cleanliness in the resident refrigerator. Interviews revealed that while dietary information was shared, safe handling practices were not. Additionally, the refrigerator was found unclean, with no records of deep cleaning, posing a risk of foodborne illnesses.
The facility failed to maintain infection control standards, as personal items were found on the clean linen folding table, and an LVN did not properly clean medical equipment or perform hand hygiene during medication administration for two residents on EBP. These issues were acknowledged by the Facility Service Director and the DON.
The facility did not implement its antibiotic stewardship program by failing to assess McGeer's criteria for four residents prescribed antibiotics in September. The facility's policies required antibiotic use to be monitored and documented, but there was no evidence of completed McGeer's forms or antibiotic surveillance tracking for these residents. Interviews with the DSD/Acting IP and DON confirmed the oversight, which potentially affected the management of antibiotic use.
A resident requiring substantial assistance with eating was left waiting for help during meals, compromising their dignity and respect. The resident, unable to make decisions and with limited range of motion, was observed asking for assistance multiple times. A CNA eventually assisted the resident while standing, which was later corrected by sitting to be at the same level.
A facility failed to provide the SNF ABN Form CMS-10055 to a resident, which is necessary for informing them of potential financial liability and appeal rights for services not covered by Medicare. The Social Services Director admitted to missing this requirement, and the facility could not provide the documentation. The Director of Nursing acknowledged the deficiency.
Unclear psychotropic behavior monitoring
Penalty
Summary
The facility failed to ensure that psychotropic medication monitoring was specific and consistent with the residents’ diagnoses for two of five sampled residents reviewed for unnecessary medications. The facility’s psychotropic medication policy stated that psychotropic medication management includes adequate indications for use, appropriate dose and duration, adequate monitoring for efficacy and adverse consequences, and gradual dose reduction unless clinically contraindicated. The report identified deficiencies in the monitoring of behaviors used to justify divalproex and escitalopram for one resident and aripiprazole for another resident. For one resident with no capacity to understand and make decisions, the record showed orders for divalproex sodium for dementia with behavioral disturbance manifested by mood lability and escitalopram for depression manifested by sad affect. Nursing documentation on the MAR recorded episodes of mood lability and sad affect across multiple shifts, but during interview the LVN stated the monitored behaviors were not specific, describing mood lability as changes from calm to excitement and sad affect as sleeping more or not smiling. The LVN agreed that if the monitored behaviors were not specific, the episodes would not be accurate and could affect gradual dose reductions or whether the medication was effective. The ADON also reviewed the record and agreed the monitored behavior manifestations were not specific. For another resident with capacity to understand and make decisions, the record showed aripiprazole ordered for depression manifested by mood swings from being pleasant to suddenly being distressed, as adjunct treatment to sertraline. The psychoactive behavior summary form listed the diagnosis and behavior for aripiprazole as depression manifested by mood swings from being pleasant and suddenly being distressed. During interview, an LVN stated she observed for side effects, behavior, or the reason the resident was on psychotropic medications, but verified that the behavior monitoring for aripiprazole was depression manifested by mood swings from being pleasant to suddenly being distressed every shift. When asked whether depression was the same as mood swings, the LVN said no. The ADON also verified that the diagnosis of depression and the behavior manifestations of mood swings for aripiprazole were not the same and needed clarification with the physician.
Failure to Follow Order for PRAFO Boot Application
Penalty
Summary
The facility failed to ensure treatment was provided according to the physician’s order for one resident with a history of multiple CVAs and left-sided hemiparesis. The resident had a physician’s order dated 6/22/22 for the RNA to apply a left PRAFO boot when in bed for positioning and to prevent contractures, and a separate order dated 12/31/22 for a left-hand splint daily for four hours as tolerated. The resident’s care plan also included interventions for the RNA to apply the left PRAFO boot when the resident was in bed and to apply the left-hand splint for four hours daily as tolerated. During observation, the resident was found in bed with the hand splint and PRAFO boot on top of the bedside drawer, and later was again observed in bed without the PRAFO boot on the left foot. The resident stated the left foot boot was not on and was usually applied for four hours, the same duration as the left-hand splint. The restorative nursing weekly summary documented that the splint was applied to the resident’s left hand and leg for four to six hours during the AM shift, with a comment that the resident refused left, but it did not specify which device was refused or on which days. The RNA stated she applied the left-hand splint and PRAFO boot to the resident’s left hand and left foot for four to six hours daily and removed them at the same time, and the ADON reviewed the record and verified the findings.
Failure to Verify Competency for PureWick Use
Penalty
Summary
The facility failed to ensure licensed nurses had the specific competencies and skill sets needed to care for residents using the PureWick external catheter. Facility policy stated that licensed staff must demonstrate the skills and techniques necessary to care for resident needs, and the PureWick policy required the licensed nurse to assess skin for compromise and perform perineal care before placing a new PureWick Female External Catheter. The facility also had in-service attendance sheets showing PureWick education was provided to licensed nurses, and a 2025 skills competency checklist that included a PureWick demo cleaning component. During interview and record review, LVN 6 confirmed Resident 36 had a PureWick external catheter and stated he received training from the IP when the resident was admitted, including sanitizing, cleaning, and application of the device. However, the 11/2024 in-service records did not show LVN 6 attended the PureWick training, and the 9/9/25 sign-in sheet only documented PureWick system cleaning, not application. The IP provided LVN 6's competency checklist showing only the PureWick demo cleaning was completed, and stated she did not assess the staff member's competency on the day he was signed off. The IP further verified that the observation of LVN 6 applying the PureWick was done on a different day, but there was no record of when that observation occurred. The Administrator, DON, and ADON were informed of the findings and acknowledged them.
Failure to Document NPI for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to ensure nonpharmacological interventions (NPI) were implemented and documented for three sampled residents receiving psychotropic medications. The deficiency was identified through observation, interview, medical record review, and review of facility policies related to psychotropic medication use. The facility policy stated that behavioral and other nonpharmacological approaches are to be used unless contraindicated, and that residents receiving psychotropic medications should receive gradual dose reductions coupled with NPI unless clinically contraindicated. For one resident with diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, psychosis, depression, and anxiety disorder, the record showed orders for divalproex and escitalopram for mood lability and sad affect. The care plan included attempts to refocus the resident and encourage expression of emotions, but the record did not show documentation of NPI implemented for the observed behaviors or whether those interventions were effective. Staff interviews indicated the resident had episodes of screaming, confusion, resistance to care, and calling out, and staff described interventions such as turning on the television, playing music, or bringing the resident to activities, but these interventions were not documented. The ADON stated NPI were implemented and documented only for residents with PRN psychotropic medications and not for residents taking psychotropic medications routinely. For another resident, the record showed orders for buspirone, Depakote, quetiapine, and bupropion for anxiety, mood disturbance, psychosis, and depression. Review of the MAR for the month reviewed did not show documented evidence that NPI were provided for screaming, crying spells, or physical and verbal aggression before administration of these medications. Staff confirmed there was no documentation of NPI provided for these behaviors. For a third resident, the record showed orders for aripiprazole and sertraline for depression and mood swings, but the MAR did not show documentation of NPI prior to administration. An LPN stated she observed for side effects, behavior, or the reason the resident was on psychotropic medications, but later stated NPI were only provided before PRN psychotropic medications. The ADON stated the facility was not providing NPI prior to administration of routine psychotropic medications, and verified that 22 residents receiving routine psychotropic medications were not receiving NPI before those medications.
Kitchen sanitation, food storage, and plumbing deficiencies
Penalty
Summary
The kitchen was found to have multiple sanitation and food safety deficiencies during surveyor observation and interview. During the initial kitchen tour, the stove hood was wiped with a paper towel and left grey sticky residue on the towel, and the fans inside Refrigerator A were observed with a greyish black fuzzy substance that also transferred to a paper towel when wiped. The fans were located directly above multiple pitchers of juices with uncovered spouts, and the DSS verified these findings. Surveyors also observed food preparation equipment and stored food that did not meet the facility’s stated standards. The can opener blade had a chipped stainless-steel coating exposing the blade. In Refrigerator B, a container of diced onions was observed with a use-by date of 12/7/25. The DSS verified the observation, and the facility’s labeling and dating policy required food items to be properly labeled and discarded after the use-by date. Food brought in from outside was also found improperly labeled and stored. In the refrigerator used for resident food brought by visitors, surveyors observed a clear plastic container with a slice of pumpkin pie labeled with resident initials and dated 12/1/25, a bag of grapes labeled with initials and room number but undated, and an opened bottle of unflavored sparkling water labeled only with a room number and undated. The DSD stated that food entering the refrigerator should be labeled with the resident’s name and date and discarded after 72 hours. In addition, the food production sink to the right of the walk-in refrigerator was observed with its drainpipe plumbed directly to the main drain, and the Maintenance Technician confirmed the sink did not have an air gap.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement its infection control surveillance program in accordance with its policy. The facility’s Surveillance for Infections policy stated the IP would conduct ongoing surveillance for healthcare-associated infections and other significant infections, and nursing staff would monitor residents for signs and symptoms of infection and document and report suspected infections. During interview, the IP stated the facility used McGeer’s criteria to determine whether a resident had an infection and that residents meeting those criteria would be included in the monthly infection surveillance log. Review of the monthly Infection Prevention and Control Surveillance Logs from January 2025 through November 2025 showed counts for HAIs, CAIs, and residents who did not meet McGeer’s criteria. When asked how the facility handled residents who showed signs and symptoms of infection but were not prescribed antimicrobial medications, the IP stated the facility did not initiate the McGeer’s criteria form for those residents and only completed a change of condition assessment. The IP also stated she was uncertain how many residents had infections and were not prescribed antimicrobial medications during that period because the facility did not initiate the McGeer’s criteria form for them. The facility also failed to establish specific testing protocols and acceptable ranges for control measures in its Legionella Water Management Program. The facility’s policy stated the water management program was intended to identify areas where Legionella could grow and spread and to reduce the risk of Legionnaire’s disease, and it referenced CDC and ASHRAE recommendations. However, review of the Water Management Program and related procedures failed to show specific testing protocols or acceptable ranges for control measures, and the Administrator and Maintenance Technician verified this finding. The facility further failed to follow its Enhanced Barrier Precautions policy for a resident with a GT. The resident had a physician’s order for EBP related to the GT. During observation, a CNA entered the resident’s room, touched and fluffed the resident’s pillow, and repositioned the pillow behind the resident while making contact with the resident’s shoulders, but the CNA was not wearing a gown. The CNA stated the resident was on EBP for the GT and acknowledged that a gown should have been worn. The facility also failed to offer hand hygiene before a resident ate lunch. The Handwashing/Hand Hygiene policy stated hand hygiene was the primary means to prevent the spread of infections and should be used before and after eating or handling food. During lunch observation, the DSD delivered the resident’s tray and opened the meal cover, but hand hygiene was not observed or heard being offered before the resident ate. The resident stated staff did not ask her to clean or wash her hands before eating, and the DSD later stated she had opened the hand wipe for the resident, which was not observed during the meal observation.
Antibiotic Stewardship Program Not Followed
Penalty
Summary
The facility failed to implement its antibiotic stewardship program in accordance with its policy and procedure for Orders for Antibiotics. The policy stated that, before calling a physician or prescriber about a suspected infection, the nurse was to have clinical signs and symptoms of suspected infection available and determine whether criteria for active infection were met based on approved definitions of infection. Instead, the facility’s Infection Preventionist stated that when a resident showed signs or symptoms of infection, the licensed nurse completed a change of condition assessment and notified the physician, and if the physician then prescribed antibiotics, the nurse who received the order initiated the McGeer’s criteria form. Facility review showed monthly Infection Prevention and Control Surveillance Logs from January 2025 through November 2025 documenting HAIs, CAIs, and residents who did not meet McGeer’s Criteria. During interview and document review on 12/8/25, the Infection Preventionist stated the facility used McGeer’s criteria to determine whether a resident had an infection, but the facility did not initiate the McGeer’s criteria form for residents with signs and/or symptoms of infection until after the physician had already prescribed antibiotics. This occurred from January 2025 through November 2025.
Bed Controller Left Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure accommodation of needs for Resident 43 by not keeping the bed controller within reach. The facility’s policy stated that residents’ individual needs and preferences are to be accommodated to the extent possible, except when health and safety would be endangered. Resident 43 was admitted to the facility and had a care plan initiated for risk for pain and discomfort related to cerebral edema and left-sided weakness. During observation and interview, Resident 43 was found in her room lying in bed and stated she was uncomfortable. When asked where the controller used to reposition her bed was located, she said she did not see it. The bed controller was observed wrapped around the resident’s television, out of her sight and reach. Resident 43 stated she repositioned herself frequently related to pain. CNA 3, who was assigned to provide care for Resident 43, confirmed the controller was out of reach and stated it should have been placed within reach before leaving the room. CNA 3 also stated the resident had left-sided weakness and required total care from staff.
Failure to Follow Care Plan for Nasal Cannula Storage
Penalty
Summary
The facility failed to implement the comprehensive care plan for Resident 2’s safe storage of a nasal cannula. Resident 2 was admitted and later readmitted to the facility, and the medical record showed a care plan problem titled At Risk for Shortness of Breath or Respiratory Distress related to COPD, revised on 11/20/25. The care plan tasks included monitoring the oxygen tubing and nasal cannula with proper storage at the bedside, initiated on 11/10/25. During observation on 12/8/25, Resident 2 was in her room with an oxygen concentrator adjacent to the bed and a nasal cannula attached to it. The nasal cannula was observed lying directly on top of the oxygen concentrator. Resident 2 stated she used oxygen to assist with breathing and that she last used oxygen that morning. LVN 5 confirmed that Resident 2 had been receiving continuous oxygen at 2 liters per minute via nasal cannula at the beginning of the shift, that Resident 2 removed her oxygen to eat breakfast, and that the nasal cannula was observed lying directly on top of the oxygen concentrator. LVN 5 stated the nasal cannula should have been stored in a clean plastic bag for infection control in accordance with the care plan.
Missed Budesonide Dose and Failure to Notify Physician
Penalty
Summary
The facility failed to ensure Resident 51 received budesonide inhalation suspension according to the physician’s order and failed to notify the physician when the medication was not available for administration. Resident 51 had diagnoses of pneumonia and acute respiratory failure with hypoxia and was admitted/readmitted to the facility from an acute care hospital on 10/5/25 at 1825 hours on continuous oxygen via nasal cannula. The physician ordered budesonide inhalation 0.5 mg/2 ml, 2 ml via nebulizer every 12 hours for respiratory failure, with the next scheduled dose due at 2100 hours on 10/5/25. The MAR showed the 2100 dose was coded as “9 = Other/see progress notes,” and the progress notes documented at 2028 hours that the facility was awaiting delivery from the pharmacy. The record did not show that the budesonide was administered on 10/5/25, and it did not show that the physician was informed that the dose was missed because the medication was not available. The ADON reviewed the record and verified that the medication should have been available within four hours of admission, that the physician should have been informed if the medication was not available at the scheduled time, and that there was no documentation that the dose was given or that the physician was notified.
Incomplete fall evaluation and missing monitoring for unassisted bed exits
Penalty
Summary
The facility failed to ensure that Resident 26’s fall risk evaluation was completed accurately after a fall on 11/19/25 and failed to monitor the resident for episodes of getting out of bed unassisted as identified in the care plan. Resident 26 was admitted with a history of falling, was cognitively intact, and required partial/moderate assistance for mobility tasks including sit-to-lying, sit-to-standing, and chair/bed-to-chair transfers. The care plan for fall risk and injury included monitoring for episodes of trying to get out of bed unassisted, based on prior incidents in which the resident was found on the floor or attempting to reach items without asking for assistance. The medical record showed multiple fall-related events, including the resident being found sitting on the floor next to a wheelchair on 3/31/25, sitting on the floor with the call light within reach and not activated on 6/9/25, and sitting on the floor with the wheelchair behind him on 11/19/25. The 11/19/25 Change in Condition Evaluation was incomplete because the resident’s most recent vital signs and pain assessment were not entered and the evaluation was not signed by the licensed nurse. The 11/19/25 fall risk evaluation also documented that the resident had no falls in the past three months and was not receiving any listed medications or medication classes, despite the resident having fallen that day and taking mirtazapine at bedtime for depression. The record also did not show documentation of monitoring for attempts to get out of bed unassisted.
Respiratory Care Deficiencies
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who were receiving oxygen therapy. For one resident, the facility failed to obtain a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. During observation, the resident was in her room with an oxygen concentrator next to her bed and a nasal cannula attached to it, with the cannula lying directly on top of the concentrator. The resident stated she used oxygen to help with breathing and had used it that morning. The LVN confirmed the resident had been receiving continuous oxygen at 2 liters per minute at the start of the shift, but also verified there was no current order for that oxygen therapy. For the second resident, the medical record showed an order for continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath to maintain an oxygen level greater than 92%. During observation, the resident was in her room and the nasal cannula attached to oxygen tubing was lying directly on top of the resident's wheelchair. The resident stated she used a portable oxygen tank with the wheelchair and had last used the nasal cannula on Saturday. The LVN verified the cannula was lying on the wheelchair and stated it should be stored in a clean plastic bag for infection control.
Inadequate Pain Assessment and Documentation Before Pain Medication
Penalty
Summary
Safe, appropriate pain management was not provided for two residents reviewed for pain management. The facility's pain medication policy stated that pain management is based on appropriate assessment and treatment of pain, and that non-pharmacological interventions such as repositioning or warm or cold compresses are to be evaluated and documented for effectiveness. Resident 5 had an order for morphine sulfate solution to be given every two hours as needed for severe pain rated 7 to 10 on a 0 to 10 pain scale. The resident did not have the capacity to understand and make decisions. On 12/9/25, the resident was administered morphine sulfate 0.5 ml by mouth for a pain level of 5, which was below the ordered parameter for use of the medication. During interview and record review, the LVN verified that morphine should not have been given for a pain level of 5 because the order was for pain levels of 7 to 10, and the ADON acknowledged the finding. Resident 10 also did not receive documented non-pharmacological intervention before pain medication was given. The resident did not have the capacity to understand and make decisions and had an order for acetaminophen, two tablets by mouth every six to eight hours for left knee pain. Review of the December 2025 MAR did not show documented evidence that NPI were provided before the acetaminophen was administered. During interview, the LVN stated the nurse was expected to assess pain, implement and document the NPI, and then give pain medication if needed, but acknowledged that the record did not show NPI had been documented. The ADON stated that NPI should be implemented and documented prior to administering pain medication and that if effective, pharmacological drugs would not be needed.
Delayed and Incorrect Transcription of Antiseizure Medication Order
Penalty
Summary
The facility failed to provide pharmacy services in accordance with its policies for Resident 43, who had a diagnosis of seizure disorder. Resident 43 had a physician's order for levetiracetam 1000 mg orally twice daily for seizures. On 12/10/25, the resident refused the morning tablet dose because the medication was being spit out, and the physician was notified. The physician then changed the medication from a tablet to a liquid solution, and the pharmacy was notified of the new order at approximately 0800 hours. The facility did not obtain the levetiracetam oral solution from the pharmacy in a timely manner, and the medication was not delivered until approximately 1430 hours. In addition, LVN 3 transcribed the physician's order incorrectly by entering levetiracetam 1000 mg oral solution as once daily instead of twice daily at 0900 hours and 1700 hours. LVN 3 later reviewed the order and stated that the transcription was an error and that the physician had ordered the medication twice a day.
Inaccurate resident documentation in MAR and skin assessments
Penalty
Summary
The facility failed to maintain an accurate medical record for three sampled residents. For one resident with a seizure disorder who was ordered levetiracetam 1000 mg twice daily, the licensed nurse told surveyors the resident refused the morning dose because the resident would spit out the tablet and that the physician was notified and changed the medication to liquid form. However, the MAR documented that the tablet was administered at the scheduled time, and the nurse verified the entry was incorrect. For another resident whose orders included monitoring depression manifested by crying spells every shift, the MAR documented 97 episodes of crying spells during one evening shift. During interview, the licensed nurse stated this was an error and that only seven episodes had occurred. The ADON also reviewed the record and verified that the MAR entry was incorrect, stating that nurses were expected to assess and document accurately in the resident’s medical record. For a third resident, the admission screening and subsequent orders documented bruising and skin discoloration to the upper extremities, with ongoing monitoring ordered for signs of swelling, skin breakdown, bleeding, and adverse bleeding. The handwritten skin assessments later showed inconsistent findings, including clear skin on some entries and old discoloration on others, and the record did not show that the physician was notified when the assessments changed from bruising to clear skin. The ADON stated the resident had been admitted with bruising from the acute care hospital and that the inconsistent documentation was a CNA documentation error.
Care Plan Not Revised for Incontinence Needs
Penalty
Summary
The facility failed to ensure the care plan for one resident was revised to address the resident’s specific care needs. Resident 36 was readmitted to the facility and had a physician’s order for a PureWick external catheter attached to a canister to drain urine every shift and as needed when in bed. The resident’s plan of care dated 1/1/25 identified a problem for episodes of bladder and bowel incontinence related to impaired mobility, dependence on staff for toileting needs, and a long history of bladder and bowel incontinence. The care plan interventions included assessing whether the resident was appropriate for a bowel and bladder retraining program or toileting program, but the medical record did not show that such an assessment was completed. During interview and record review, the MDS Coordinator stated the resident was not a candidate for bowel and bladder retraining or toileting and verified there was no documentation of an assessment. The MDS Coordinator also confirmed the care plan should have been revised to remove the intervention to assess for retraining or toileting once the resident was determined not to be a candidate.
Failure to Timely Send Discharge Documents to HHA
Penalty
Summary
The facility failed to send the required discharge referral documents to the home health agency (HHA) for a resident, resulting in the resident not receiving necessary ongoing care. The facility's policy and procedure (P&P) for discharge summary and plan, revised in October 2022, mandates that the post-discharge plan be developed by the care planning team with the resident and family, including arrangements for follow-up care. However, a complaint was received by the California Department of Public Health (CDPH) indicating that the resident did not receive physical therapy (PT) services until 12 days after discharge, when the PT order was finally faxed. The resident was discharged with orders for home health services, including registered nurse (RN) services for medication management and PT services for safety. Despite this, the discharge team delayed sending the necessary documents to the HHA. The facility's social services director (SSD) admitted to forgetting to fax the required documents until prompted by a call from the resident's family member. The director of nursing (DON) was informed and acknowledged these findings, confirming the lapse in procedure that led to the resident's lack of timely care post-discharge.
Failure to Conduct Entrapment Risk Assessments for Bed Side Rails
Penalty
Summary
The facility failed to ensure the safety of 13 residents who were using bed side rails, as they did not complete the necessary entrapment risk assessments prior to their use. This oversight was identified through observations, interviews, and reviews of medical records and facility policies. The residents involved had varying degrees of cognitive and physical impairments, which necessitated the use of side rails for bed mobility and safety. However, the facility did not document the required assessments to evaluate the risk of entrapment, which is crucial for preventing potential injuries. The report highlights specific cases where residents were observed with elevated side rails without documented evidence of entrapment assessments. For instance, Resident 35, who had moderate cognitive impairment and required assistance with bed mobility, was using side rails without a completed entrapment assessment. Similarly, Resident 41, who was cognitively intact but had decreased mobility, also lacked documented evidence of such an assessment. These omissions were consistent across all 13 residents reviewed, indicating a systemic issue within the facility's processes. Interviews with facility staff, including the Resident Assistant (RA) and the Director of Nursing (DON), revealed that the necessary measurements and assessments were not conducted. The RA admitted to generally measuring beds but not specifically for each resident's size and weight, which is essential for ensuring safety. The DON was made aware of these findings, acknowledging the lack of compliance with the facility's policies and procedures regarding side rail use and entrapment risk assessments.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitary requirements in the kitchen, as observed during a survey. Staff did not perform proper handwashing before donning gloves while preparing food, which is a violation of both the facility's policy and the USDA Food Code. This was observed when a staff member, after touching various kitchen equipment, resumed food preparation without washing hands before putting on gloves. The Food Services Director acknowledged this lapse in protocol. Additionally, the facility did not ensure proper labeling and dating of opened food items in the freezer, leading to potential food safety risks. Several food items, including corn kernels, lobsters, and various meats, were found unsealed, undated, and appeared freezer burned. An expired cooked pork shoulder was also found stored in the freezer. The Food Services Director confirmed these findings and acknowledged the need for better monitoring of food labeling and usage. The facility also failed to maintain cleanliness and proper storage conditions for food preparation equipment and storage areas. A container of thickener was found improperly sealed, and several pieces of kitchen equipment, including a frying pan and scoops, were in poor condition with residue buildup. Additionally, a large pot was stored while still wet, and the ice machine was found with slimy and black residues. These conditions were verified by the Food Services Director, indicating a lack of adherence to sanitation protocols as outlined in the USDA Food Code and the facility's policies.
Failure to Conduct Entrapment Assessments for Residents Using Bed Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments were completed and measurements recorded during bed inspections for 13 residents who used bed rails. The facility's policies and procedures required assessments for risks of entrapment and proper installation and maintenance of bed rails. However, these assessments were not conducted, and there was no documented evidence of routine bed inspections to identify potential entrapment areas. The facility's document titled 'Bed Zone Measurements' showed that Zone 5 was not inspected for possible entrapment, indicating a gap in the inspection process. During an interview, the RA admitted to generally conducting bed zone measurements but not inspecting or measuring the bed's dimensions according to the resident's size, weight, and height, or when there was a change of bed or mattress. This oversight had the potential to negatively impact residents, resulting in possible entrapment, serious injury, or death. The residents involved were observed using side rails, but their medical records lacked evidence of completed entrapment risk assessments and appropriate bed dimension measurements.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident, identified as Resident 545, by not ensuring the call light was within reach and accessible. During an observation and interview, it was noted that Resident 545, who had a blue sling on her right arm due to a fall at home, was unable to reach the call light, which was clipped to the outer side of the left upper bed rail. The resident mistakenly used the bed remote, thinking it was the call light, indicating a lack of understanding and accessibility. The resident expressed concerns about not receiving timely assistance when needing help to go to the restroom. Medical records revealed that Resident 545 had fluctuating capacity to understand and make decisions, with a BIMS score indicating cognitive intactness but requiring substantial to maximal assistance with toileting hygiene and mobility. An LVN confirmed the call light was not within reach and subsequently placed it within reach while instructing the resident on its use. The DON acknowledged the expectation for call lights to be within reach and promptly answered, confirming the deficiency in meeting these standards.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. For one resident, who was prescribed Levaquin for a urinary tract infection (UTI), the facility did not document a care plan problem to address the use of this antibiotic. This oversight was confirmed during interviews with the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), who acknowledged the absence of a care plan for the resident's antibiotic treatment. Another resident, who used a PureWick catheter, did not have a care plan addressing the risk of infection prevention and control. The facility failed to educate the resident and their family on the timely provision of PureWick catheter supplies and the proper cleaning of the collection canister, collector, and pump tubing. Observations revealed that the PureWick collection canister had a dry, dark green residue, and there was no documentation of when it was last cleaned or changed. Interviews with LVNs and the ADON confirmed the lack of a care plan and the absence of education provided to the resident and their family. These deficiencies posed a risk of not providing appropriate, consistent, and individualized care to the residents. The Director of Nursing (DON) was informed and acknowledged the findings, confirming the facility's failure to develop necessary care plans for the residents' specific needs.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure injuries and promote healing of existing ones for a resident. The resident developed a Stage 3 pressure injury to the coccyx after admission. The facility did not provide high protein snacks at bedtime as recommended by the registered dietitian (RD), which was part of the care plan to address the resident's risk for altered nutritional status and skin breakdown. The care plan was not updated to reflect the RD's recommendation for high protein snacks, despite the resident's worsening condition. Additionally, during a wound care observation, a licensed vocational nurse (LVN) did not use a protective barrier as per the facility's policy and procedure (P&P) during wound care, exposing the wound to the resident's diaper. This failure was acknowledged by the LVN and the Director of Nursing (DON), who confirmed that the Stage 3 pressure injury developed in the facility. The RD also verified that high protein snacks, such as cottage cheese and yogurt, were recommended but not provided as ordered.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for two residents, one with a PureWick catheter and another with an indwelling urinary catheter. For the first resident, the staff did not ensure proper monitoring and care of the PureWick collection canister, which was observed to have dry, dark green residue. The staff, including LVNs and the ADON, were unfamiliar with the PureWick catheter care, and there was no documentation of when the canister and tubing were last cleaned or changed. Additionally, not all staff attended the in-service training on PureWick catheter care, contributing to the deficiency. The second resident's indwelling urinary catheter drainage bag was improperly positioned on the floor under the bed, which could lead to inadequate urinary drainage and resident discomfort. The care plan for this resident included instructions to keep the drainage system closed and the collection unit positioned below the bladder, but these were not followed. The ADON confirmed the improper placement of the drainage bag and corrected it by hanging it on the bed frame. Both residents were at risk of developing catheter-associated urinary tract infections due to these deficiencies. The facility's failure to ensure proper catheter care and monitoring, as well as inadequate staff training and documentation, contributed to the risk of infection for these residents.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically regarding the maintenance of the storage bag for the Yankauer suction tip. Resident 38, who lacked the capacity to understand and make decisions, had a physician's order to suction oral secretions as needed for excessive secretions. During an observation and interview, it was verified that the storage bag for the Yankauer suction tip was dated 10/4/24 and had not been changed weekly as required. LVN 5 confirmed that the storage bags were supposed to be changed weekly on Thursdays to ensure infection control and limit bacteria buildup. The Director of Nursing acknowledged that the respiratory supplies and storage bags were expected to be replaced weekly or as needed, and that the storage bag for Resident 38 should have been replaced.
Deficiencies in Infection Preventionist Certification and PureWick Catheter Care
Penalty
Summary
The facility failed to ensure that the Director of Staff Development (DSD) and Acting Infection Preventionist (IP) maintained an updated Certification of Infection Preventionist Training Course. The certification was last completed on 9/11/22, and during an interview, the Acting IP acknowledged that it was overdue. The Director of Nursing (DON) confirmed these findings, indicating a lapse in maintaining current infection prevention and control competencies as required by the facility's policies and procedures. Additionally, the facility did not ensure that nursing staff were competent in the care of a resident's PureWick catheter system. The manufacturer's guidelines for cleaning and maintaining the PureWick system were not followed, as evidenced by the presence of a dry, dark green residue in the collection canister. Interviews with two Licensed Vocational Nurses (LVNs) revealed that they were unfamiliar with the care procedures for the PureWick system, and not all staff attended the in-service training on this topic. The Assistant Director of Nursing (ADON) and the DSD/Acting IP acknowledged that the PureWick catheter care was new to the staff and that the in-service training should have been provided to all facility staff.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and reconciliation of controlled medications for a nonsampled resident, identified as Resident 42. The deficiency was identified through a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy on controlled substances, revised in November 2022, requires monitoring and reconciliation of controlled substance inventory to prevent loss or diversion. However, a review conducted on October 23, 2024, revealed that the Controlled Medication Count Sheet for Resident 42's hydrocodone/acetaminophen did not match the Medication Administration Record (MAR). Specifically, the medication was signed out by a nurse on September 28, 2024, at 0600 hours, but there was no corresponding documentation in the MAR or Medication Administration Notes indicating that the medication was administered to the resident. Interviews with facility staff, including an LVN and the ADON, confirmed the discrepancy between the Controlled Medication Count Sheet and the MAR. The medical record review showed that Resident 42 had a physician's order for hydrocodone/acetaminophen to be administered as needed for moderate to severe pain. Despite this order, the MAR lacked documentation of administration for the medication on the specified date and time. The DON was informed of these findings and acknowledged the issue, highlighting a failure in the facility's pharmaceutical services to ensure accurate medication administration and reconciliation.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. During a medication administration observation, a licensed nurse (LVN 1) was found to have made errors while administering medications to two nonsampled residents. For Resident 11, LVN 1 did not follow the facility's policy and procedure for administering eye drops. Instead of gently pulling down the lower eyelid to form a pouch and instructing the resident to look up, LVN 1 administered the eye drops directly into the inner corner of the eyes and used more than the prescribed amount. This resulted in the need to use an additional vial of medication for the resident's right eye. For Resident 29, LVN 1 administered methenamine hippurate without food, contrary to the physician's order that specified the medication should be given with food. LVN 1 acknowledged administering the medication late and without food. These actions were confirmed during interviews with LVN 1 and the Director of Nursing (DON), who acknowledged the findings.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during an inspection of Medication Cart A. The inspection revealed that nitroglycerine tablets were not disposed of by their discard date, and various medications, including diclofenac sodium topical gels and lidocaine patches, were improperly stored together. Additionally, external and internal medications were not stored separately, and an opened container of sanitizing wipes was stored with other medications. The facility's policy on medication labeling and storage was not adhered to, leading to these deficiencies. Further deficiencies were noted in the monitoring and documentation of glucose quality control for the glucometer. The Glucometer Evencare Diabetes Care System Quality Control Log Sheet showed discrepancies in the lot strip numbers and dates, indicating a lack of accurate monitoring. Additionally, the treatment cart inspection revealed expired and improperly labeled items, such as opened syringes, expired wound packing strips, and unlabeled ointments. These findings were verified by the LVN and acknowledged by the DON. The facility also failed to maintain accurate records of the Medication Room and Refrigerator Temperature Logs. Missing documentation was noted on several dates, with no recorded temperatures or staff initials. The ADON confirmed these omissions, acknowledging that the assigned staff should have checked, recorded, and signed the logs. The DON verified these findings, indicating a systemic issue in maintaining accurate temperature records, which is crucial for ensuring medication efficacy and safety.
Failure to Provide Resident's Preferred Meal Option
Penalty
Summary
The facility failed to adhere to the food preferences of a resident, identified as Resident 25, during a dining observation. Despite the meal ticket indicating a preference for a high-calorie chocolate shake, Resident 25 was served a strawberry shake. This discrepancy was confirmed during an observation and interview with CNA 5, who acknowledged that Resident 25 usually received a chocolate shake but was unsure why a strawberry shake was provided instead. Resident 25 expressed a preference for the chocolate shake, which was not honored at the time of meal service. Further investigation involved the Registered Dietitian (RD), who verified that the meal ticket reflected the resident's preference for a chocolate shake. The RD confirmed that chocolate shakes were available in the kitchen but were not provided to Resident 25 during meal preparation. The Director of Nursing (DON) later acknowledged these findings, indicating a lapse in the facility's adherence to its policy on resident food preferences, which requires that individual preferences be assessed and communicated to the interdisciplinary team upon admission.
Deficiencies in Food Safety and Refrigerator Cleanliness
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the safe handling and storage of food brought in by residents' family members or visitors. There was no documented evidence that safe food handling instructions were provided to those bringing food from outside, which is a requirement under CMS guidelines. Interviews with an LVN and the RD revealed that while family members were informed about the type and consistency of the resident's diet, they were not educated on safe food handling practices, including proper hygiene. This oversight had the potential to cause foodborne illnesses among the medically vulnerable resident population. Additionally, the facility did not maintain cleanliness in the resident refrigerator, as observed during an inspection. The refrigerator was found to have dust and black residue, indicating a lack of proper sanitation. Although the Facility Services Director stated that refrigerators were cleaned daily and deep cleaned monthly, there was no documented record of these deep cleanings. The DON was informed of these findings and acknowledged the issues, highlighting a failure in maintaining a hygienic environment for residents.
Infection Control Lapses in Linen Handling and Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program as per its policies and procedures. During an observation, it was noted that the clean linen folding table in the laundry room had personal items, including a white portable fan and a black stationary storage container, which the Facility Service Director acknowledged could lead to contamination of clean linens. Additionally, during a medication administration observation, an LVN did not completely clean the blood pressure cuff, pulse oximeter, and thermometer before obtaining vital signs from a resident who was on Enhanced Barrier Precautions (EBP) due to the use of a urinary indwelling catheter. Furthermore, another observation revealed that the same LVN failed to perform hand hygiene before and after removing gloves while administering medication through a gastrostomy tube (GT) for a resident also on EBP. The LVN confirmed not performing the necessary hand hygiene steps. These lapses in infection control practices were acknowledged by the Director of Nursing (DON) during interviews, indicating a potential risk for the spread of infection among staff and residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not conducting assessments using the McGeer's criteria to determine true infections for four residents who were prescribed antibiotics in September. This oversight involved two sampled residents and two non-sampled residents. The facility's policies and procedures, revised in December 2016, required that antibiotics be prescribed and administered under the guidance of the antibiotic stewardship program, which includes reviewing discharge and transfer paperwork for current antibiotic orders. Additionally, the facility's policy mandated that all clinical infections treated with antibiotics undergo review by the infection preventionist or designee, and that antibiotic regimens be documented on a facility-approved antibiotic surveillance tracking form. The facility's Monthly Infection Surveillance Report for September 2024 indicated that four residents were admitted from an acute care hospital with antibiotics, but there was no documentation that the McGeer's form or an antibiotic surveillance tracking form was completed for these residents. Interviews with the DSD/Acting IP and the DON confirmed that the facility did not assess the McGeer's criteria for these residents. The DSD/Acting IP stated that the purpose of the antibiotic stewardship program was to limit excess antibiotic use and to discuss with physicians whether an antibiotic was still needed or could be discontinued. The failure to complete the necessary forms and assessments potentially inhibited the ability to accurately identify true infections and manage antibiotic use effectively.
Failure to Assist Resident with Meals in a Respectful Manner
Penalty
Summary
The facility failed to promote the dignity and respect of a resident who required assistance with eating. The resident, who had no capacity to understand and make decisions and required substantial assistance with eating due to limitations in range of motion, was observed on multiple occasions waiting for assistance to eat meals. On one occasion, the resident was found lying in bed with a breakfast tray in front of him, stating that no one had assisted him to eat and asking the surveyor for help. Later, the resident was observed again with a meal tray in front of him, expressing hunger and asking when someone would assist him. During the lunch meal, a CNA set up the resident's tray but informed the resident to wait for assistance, as the CNA was assigned to another resident. The resident continued to ask when someone would come to feed him. Eventually, the CNA assisted the resident while standing over him, which was later corrected by sitting down to be at the same level as the resident. The Director of Nursing was informed and acknowledged these findings, indicating a failure to treat the resident with respect and dignity.
Failure to Provide SNF ABN Form to Resident
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 to a resident reviewed for beneficiary notification. This form is essential for informing residents of their potential financial liability and their rights to appeal if they choose to receive services not covered by Medicare. During a medical record review and interview with the Social Services Director (SSD), it was revealed that the resident had skilled days remaining but was discharged from Medicare Part A services while continuing to reside in the facility. The SSD admitted to missing the provision of the SNF ABN form to the resident, and the facility was unable to provide the necessary documentation. The Director of Nursing (DON) was informed and acknowledged the finding.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Stanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Grove Post Acute | 1 mi | ★★★★★ | 4 | 0 |
| Extended Care Hospital Of Westminster | 1.7 mi | ★★★★★ | 1 | 0 |
| Mission Palms Healthcare Center | 1.9 mi | ★★★★★ | 23 | 0 |
| Coventry Court Health Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Beach Creek Post-acute | 2.7 mi | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.