Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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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.
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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 | — | 0 | 0 |
| Extended Care Hospital Of Westminster | 1.7 mi | — | 1 | 0 |
| Mission Palms Healthcare Center | 1.9 mi | — | 0 | 0 |
| Coventry Court Health Center | 2.7 mi | — | 1 | 0 |
| Beach Creek Post-acute | 2.7 mi | — | 27 | 0 |
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