Inspection visit

InspectionMarch 3, 2023

ROWNTREE GARDENSCMS #55571828 citations on this visit

28 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 28 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview, medical record, facility P&P review, and facility document review, the facility failed to ensure the staff provided care and promoted dignity and respect for one of 14 final sampled residents (Resident 16) and one nonsampled resident (Resident 7). * CNA 1 was observed going into Rooms A, B, C, and D without knocking during a dining observation. * RNA 1 was observed assisting Residents 7 and 16 with meals at the same time. RNA 1 was also observed standing over Resident 16 while assisting the resident with meals. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Dignity revised 2/2021 showed the staff are expected to knock and request permission before entering the residents' rooms. Review of the facility's P&P titled Assistance with Meals revised 3/2022 showed the residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example not standing over resident while assisting them with meals. 1. During the initial dining observation, CNA 1 was observed not knocking before entering the residents' rooms. For example: - On 2/28/23 at 1220 hours, CNA 1 was observed holding a lunch tray and entering Room A without knocking. CNA 1 was observed placing the lunch tray in front of Resident 16, then exited the room. - On 2/28/23 at 1221 hours, CNA 1 was observed holding a lunch tray and entering Room A without knocking. CNA 1 was observed placing the lunch tray in front of Resident 7, then exited the room. - On 2/28/23 at 1228 hours, CNA 1 was observed entering Room B without knocking. - On 2/28/23 at 1229 hours, CNA 1 was observed entering Room C without knocking, and exited the room. Then CNA 1 was observed re-entering Room C without knocking. - On 2/28/23 at 1231 hours, CNA 1 was observed entering Room D without knocking. On 2/28/23 at 1232 hours, an interview was conducted with CNA 1. CNA 1 verified the above findings. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 43 Event ID: 555718 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm CNA 1 stated she was holding a lunch tray while entering and she was unable to knock. When asked if she could have at least spoke and ask permission to enter the residents' rooms, CNA 1 stated she was so focus on what she was doing and may have forgotten to knock and ask permission before entering the residents' rooms. CNA 1 acknowledged she should have introduced herself and let the residents know she was entering their room. Residents Affected - Few On 3/1/23 at 1545 hours, an interview and concurrent the facility P&P review was conducted with the DSD. The DSD stated the staff were supposed to knock before entering the residents' rooms, and to always introduce themselves or their name to the residents to promote the residents' dignity. 2. On 3/2/23 at 0826 hours, RNA 1 was observed assisting Resident 16 with meals. RNA 1 was observed cutting the resident's donut and was standing over Resident 16. Then RNA 1 was observed sitting beside Resident 7 and fed the resident. On 3/2/23 at 0828 hours, RNA 1 was observed standing up, went over to Resident 16 and cut up Resident 16's food. Then RNA 1 was observed sitting beside Resident 7 and fed the resident. On 3/2/23 at 0828 hours, RNA 1 was observed standing up, went over to Resident 16, and offered food to Resident 16. Then RNA 1 was observed sitting beside Resident 7 and fed the resident. On 3/2/23 at 0837 hours, RNA 1 was observed standing up, went over to Resident 16, and offered food to Resident 16. Then RNA 1 was observed sitting beside Resident 7 and fed the resident. On 3/2/23 at 1437 hours, an interview was conducted with RNA 1. RNA 1 verified the findings. RNA 1 verified she was assisting two residents at the same time for feeding. RNA 1 stated she was feeding Resident 7 and cuing and assisting Resident 16 with her food. RNA 1 verified she was standing over Resident 16 while she was assisting the resident with her meals. RNA 1 stated she was told it was okay to assist two residents with feeding at the same time, but she was also told to sit down while assisting the residents with feeding. On 3/2/23 at 1540 hours, an interview was conducted with the DSD. The DSD stated it was not recommended to feed two residents at the same time, because it was not proper. The DSD stated it was okay for the staff to stand up when cutting up the resident's food or helping with the resident's food; however, it was recommended for the staff to sit down while feeding the residents. Cross reference to F880, example #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 2 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility P&P review, the facility failed to determine if it was safe for one nonsampled resident (Residents 405) to self-administer the medications. Residents Affected - Few * Resident 405 was observed with a cup containing several Lactaid (enzyme supplement) medication at bedside. Resident 405 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medications. This had the potential for Resident 405 to administer medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 2/2021 showed as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. Any medication found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. On 2/28/23 at 1201 hours, Resident 405 was observed lying in bed, with a plastic cup containing several white tablets near her lunch tray on her overbed table. Resident 405 stated those were Lactaid medications, and she had been taking the medication by herself, prior to eating her meals. Resident 405 stated her daughter brought the medication last Saturday (2/25/23), and the nurses were aware. Medical record review for Resident 405 was initiated on 2/28/23. Resident 405 was admitted to the facility on [DATE]. Review of Resident 405's MDS dated [DATE], showed Resident 405 was cognitively intact and without impairment to the upper extremities. Review of the resident's medical record failed to show a physician's order for the Lactaid medication, nor an assessment was completed for Resident 405 to safely self-administer medications. Review of the plan of care failed to show a care plan problem was developed to address Resident 405's self-administration of the Lactaid medications. On 2/28/23 at 1207 hours, an observation for Resident 405 and concurrent interview and concurrent medical record review was conducted with the ADON. The ADON was called to Resident 405's room and verified the above findings. Resident 405 stated she had the bottle of the Lactaid medication inside her bedside drawer. The ADON was observed opening Resident 405's bedside drawer and found a bottle of the Lactaid medication. On 3/3/23 at 1059 hours, an interview and concurrent medical record review and facility P&P review for Resident 405 was conducted with the DON and ADON. When asked how the residents were evaluated to self-administer medication, the ADON stated a self-administration assessment would be completed if the resident wished to self-administer their medications, and the resident had the cognitive and physical ability to self-administer their medications. The ADON stated if a resident was assessed to be able to self-administer her medication, the resident should be provided with a locked drawer to store the medications. The ADON stated there should be a physician's order for the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 3 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm self-administration of medication, and this should be addressed in the care plan. When asked if it was appropriate for Resident 405 to keep medications at the bedside if there was no assessment for the resident to able to self-administer medications, the DON stated no. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 4 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to maintain a copy of the resident's advance directives in the medical record for one of 14 final sampled residents (Resident 40). This had the potential for Resident 40's decisions regarding her healthcare and treatment options not being honored. Findings: Medical record review for Resident 40 was initiated on 2/28/23. Resident 40 was readmitted to the facility on [DATE]. Review of the POLST dated 2/25/19, showed Resident 40 had an advance directive. Review of the Advanced Healthcare Directive (AHCD) Acknowledgment Form dated 2/8/23, showed Resident 40 had an advance directive. The boxed for copy requested by facility was checked. Review of Resident 40's medical record failed to show a copy of the advance directive was maintained in Resident 40's medical record. On 3/1/23 at 1614 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified a copy of Resident 40's advance directive was not maintained in Resident 40's medical record nor was it uploaded to Resident 40's electronic health record. The SSD stated the residents and/or their family or representative were asked upon admission if they had formulated an advance directive. The SSD stated if the resident had and advance directive, the facility would ask for a copy of the advance directive; and the social services would have to follow up right away if the resident or representative could not provide a copy of the advance directive. The SSD stated they would have to document any follow up done by the facility regarding Resident 40's advance directives. The SSD could not provide documentation for following up Resident 40's advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 5 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the transfer to the acute care hospital for one of three closed record sampled residents (Resident 50). This failure had the potential of not providing Resident 50 with access to an advocate who could inform them of their options or rights related to transfer. Findings: Review of the facility's P&P titled Transfer or Discharge Notice dated 3/2021 showed a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of the facility's document titled Notice of Transfer and Discharge with effective discharge date of 1/6/23, failed to show documented evidence the State Long-Term Care Ombudsman was notified of Resident 50's transfer to the acute care hospital. Closed medical record review for Resident 50 was initiated on 3/3/23. Resident 50 was admitted to the facility on [DATE], readmitted on [DATE], and transferred to the acute care hospital on 1/6/23. Review of the Progress Notes dated 1/1 to 1/6/23, failed to show documentation of Resident 50's transfer to the acute care hospital notification to the Ombudsman. On 3/3/23 at 1005 hours, a concurrent interview and facility document review was conducted with LVN 4. LVN 4 stated the Ombudsman was notified upon a resident's discharge or transfer via faxing a copy of the Notice of Transfer and Discharge document, and a copy of the fax confirmation would be placed in the resident's medical record. LVN 4 was unable to show a copy of the fax confirmation for the Notice of Transfer and Discharge document nor documentation where the Ombudsman was notified of Resident 50's transfer to the acute care hospital. On 3/3/23 at 1043 hours, an interview and concurrent facility document review was conducted with the MRD. The MRD verified the above findings and was unable to locate the copy of the fax confirmation for the Notice of Transfer and Discharge document in Resident 50's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 6 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to show an accurate assessment that represented an accurate picture of the residents' status during the observation period of the MDS for one of 14 final sampled residents (Resident 28). This failure had the potential for Resident 28's care needs not being met. Residents Affected - Few Findings: Medical record review for Resident 28 was initiated on 2/28/23. Resident 28 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 28's Order Summary Report showed an order dated 12/7/22, for a No Concentrated Sweets (NCS - a liberalized diet to keep blood sugar levels under control) diet, regular texture, and consistency. Review of Resident 28's plan of care dated 10/10/22, showed a care plan problem addressing Resident 28 required extensive assistance (resident involved in activity) by one staff member with eating oral diet. Review of Resident 28's MDS, under the functional status section dated 10/12/22, and 1/9/23, showed Resident 28's eating status was total dependence (full staff performance every time during entire seven-day period). Review of Resident 28's medical record tilted ADLs (Activities of Daily Living), under the eating section, between the dates of 10/6/22 to 10/12/22, and 1/3/23 to 1/9/23, showed Resident 28 mostly required extensive assistance with the help of one person. On 3/2/23 at 0755 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 28 required total assistance except when eating and needed extensive assistance or supervision from staff. On 3/2/23 at 0818 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated she was responsible of the assessment of residents upon admission and quarterly thereafter. The MDS Coordinator stated she would gather her data based on staff interviews, documentation, observation, and interviews with the residents. The MDS Coordinator was shown the resident's MDS assessments dated 10/6/22, and 1/9/23. The MDS Coordinator stated she would look at the look back period when the assessments for the MDSs shown were completed. The MDS Coordinator further stated she based her assessment with the resident's most dependent assistance. On 3/3/23 at 0819 hours, a follow-up interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 28's MDS assessments completed on 10/12/22, and 1/9/23, were based on staff documentation which showed the resident mostly required extensive assistance with the help of one person. The MDS Coordinator verified the MDSs dated 10/12/22, and 1/9/23, were coded in error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 7 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 38) on hospice services attained and maintained the highest practicable well-being. Residents Affected - Few * The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visits. This had the potential of a delay in hospice care regarding changes in Resident 38's condition. Findings: Medical record review for Resident 38 was initiated on 2/28/23. Resident 38 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 3/9/22, for Resident 38 to be admitted to hospice services under a routine level of care. Review of the hospice projected calendar showed the following: - For December 2022, there were no documentation for visitation frequencies for the RN/LVN, CHHA, SC, and MSW. Further review of the hospice calendar showed the RN/LVN was scheduled to visit on 12/6, 12/8, 12/13, 12/14/22; the CHHA was to visit on 12/2, 12/5, 12/7, 12/9, 12/12, 12/14/22; and the SC was to visit on 12/12/22. There were no RN/LVN and CHHA scheduled visits for the weeks of 12/18/22 to 12/24/22, and 12/25/22 to 12/31/22. - For January 2023, the RN/LVN was scheduled to visit two times per week, the CHHA was scheduled to visit three times per week, and the SC and MSW was scheduled to visit once a month. However, the hospice calendar failed to show the scheduled visitation days for the RN/LVN and CHHA. - For February 2023, the RN/LVN was scheduled to visit two times per week, the CHHA was scheduled to visit three times per week, and the SC and MSW were scheduled to visit once a month. Further review of the hospice calendar showed the RN/LVN was scheduled to visit on 2/2, 2/6, 2/8, 2/14, 2/16, 2/20, 2/22, 2/28/23; the CHHA was scheduled to visit on 2/1, 2/3, 2/6, 2/8, 2/10, 2/13, 2/15, 2/17, 2/20, 2/22, 2/24, 2/27/23; the SC was scheduled to visit on 2/11/23; and the MSW was scheduled to visit on 2/27/23. Review of the hospice untitled and undated documents, and hospice visit notes showed Resident 38 was visited by the hospice's staff as follows:: - For December 2022, Resident 38 was visited by the RN/LVN on 12/6, 12/8, 12/13, 12/14, 12/20, 12/22, and 12/28/22. However, the RN/LVN visited Resident 38 only once on the week of 12/25 to 12/31/22. There was no documented visits of the hospice CHHA. - For January 2023, Resident 38 was visited by the RN/LVN on 1/3, 1/6, 1/10, 1/13, 1/17, 1/20, and 1/31/23. However, there was no documented visits of the RN/LVN during the week of 1/22 to 1/28/23. In addition, the RN/LVN visited Resident 38 only once during the week of 1/29 to 2/4/23. There were no documented visits of the hospice CHHA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 8 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm - For February 2023, Resident 38 was visited by the RN/LVN on 2/7, 2/8, 2/14, 2/116, 2/21, and 2/22/23. However, there was no documented visits by the RN/LVN during the week of 2/26 to 3/4/23. Review of the facility's record titled Quality Assessment/Improvement Hospice Monitor showed Resident 38's hospice audit was on 3/2/22. Residents Affected - Few Further review of Resident 38's medical record failed to show the hospice Sign-In Form for the months of December 2022, January, and February 2023. On 3/3/23 at 1320 hours, an observation was conducted with Resident 38. Resident 38 was observed in bed and appeared to be well groomed; and the television was on. On 3/323 at 1329 hours, an interview was conducted with CNA 2. CNA 2 stated the hospice CHHA would come on Mondays, Wednesdays, and Fridays. On 3/3/23 at 1403 hours, an interview was conducted with LVN 4. LVN 4 stated the hospice CHHA would come three times a week, and the RN/LVN would come two times a week. LVN 4 stated the hospice CHHA would let the facility staff electronically signed in when they visited. LVN 4 further stated the Medical Records staff was responsible for checking the hospice documentation. On 3/3/23 at 1411 hours, a concurrent interview and medical record review was conducted with the Medical Records Assistant. The Medical Records Assistant stated she was responsible for checking the hospice missing documents. The Medical Records Assistant verified the findings and stated after the initial audit for Resident 38's hospice documents, she audited the hospice certification and calendar. On 3/3/23 at 1427 hours, an interview was conducted with the ADON. The ADON stated she was assigned to check the hospice documentations. The ADON further stated the hospice should have a log to show how often the hospice staff visited Resident 38. On 3/3/23 at 1438 hours, a follow-up interview and concurrent medical record review was conducted with the ADON. The ADON was informed and acknowledged the above findings. On 3/3/23 at 1614 hours, an interview with the ADON was conducted with the DON present. The DON stated when the hospice staff visited Resident 38, they would let the facility staff sign-in electronically. The DON stated the hospice staff should follow the visitation frequency in their projected calendar. The ADON stated the facility tried calling the hospice agency about the missing documents and was told that the hospice would provide the missing documents. The DON acknowledged the above findings. On 3/3/23 at 1620 and 1758 hours, a follow-up interview was conducted with the DON. The DON stated there was no additional documents provided from the hospice agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 9 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 2/28/23 at 0830 hours, Resident 8 was observed in bed. A bag containing a nasal annular tubing was dated 2/12/23. The humidifier connected to the oxygen concentrator was dated 2/13/23. A bag containing a nebulizer mask was dated 2/24/23, but was not labeled with the resident's name per the facility's P&P. Residents Affected - Few Medical record review for Resident 8 was initiated on 2/28/23. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed the following physician's orders: - dated 1/21/23, to administer budosenide suspension (a synthetic steroid that reduces inflammation in the body) 0.5 mg/2 ml via nebulizer every 12 hours for asthma; and - dated 2/8/23, to administer oxygen two liters per minute via nasal annular as needed to keep oxygen saturation level greater than 92%. Review of Resident 8's Medication Administration Record for February 2023 showed Resident 8 was administered budosenide suspension via inhalation from 2/1 to 2/28/23 at 0900 and 2100 hours, and oxygen on 2/13 and 2/16/23. On 2/28/23 at 1059 hours, an observation for Resident 8 and concurrent interview was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 also verified the resident's nasal cannula bag was dated 2/12/23, and humidifier was dated 2/12/23. LVN 2 acknowledged Resident 8 was being administered nebulizer routinely and oxygen as needed. LVN 2 stated the oxygen nasal cannula, humidifier, and nebulizer mask and tubing were supposed to be changed every Thursday by the NOC (2300 - 0700 hours) nurse. 5. On 2/28/23 at 0923 hours, Resident 403 was observed in bed. A bag containing a nasal cannula was dated 2/16/23. A bag containing a nebulizer mask was undated and not labeled with the resident's name per the facility's P&P. Medical record review for Resident 403 was initiated on 2/28/23. Resident 403 was initially admitted to facility on 2/5/23, and readmitted to the facility on [DATE]. Review of Resident 403's Order Summary Report showed the following physician's order dated 2/22/23: - To administer oxygen at three liters per minute via nasal annular as needed for SOB and wheezing, to maintain oxygen saturation level more than 92%; and - ipatropium-albuterol solution (bronchodilator, used to treat air flow blockage in the lungs) 0.5-2.5 mg/3 ml one vial inhale two times a day for SOB or wheezing. Review of Resident 403's Medication Administration Record for February 2023 showed Resident 403 was administered ipratropium-albuterol solution via inhalation from 2/23 to 2/28/23 at 0900 and 1700 hours, and oxygen on 2/23/23. On 2/28/23 at 1057 hours, an observation for Resident 403 and concurrent interview was conducted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 10 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with LVN 1. LVN 1 verified the above findings. LVN 1 acknowledged Resident 403 was on continuous oxygen. LVN 1 stated the nasal cannula and nebulizer mask and tubing were supposed to be labeled with the resident's name and date, and these were to be changed every Thursday by the NOC (2300 - 0700 hours) nurse. 6. Medical record review for Resident 25 was initiated on 2/28/23. Resident 25 was readmitted to the facility on [DATE]. Review of Resident 25's History and Physical examination dated 2/2/23, showed a diagnosis of COPD. Review of Resident 25's Order Summary Report showed an order dated 2/6/23, to administer budesonide inhalation suspension 0.5 mg/2 ml, inhale 2 ml orally by nebulizer two times a day for COPD. Review of Resident 25's electronic Medication Administration Record dated February 2023 showed to administer budesonide inhalation suspension 0.5 mg/2 ml, inhale 2 ml orally by nebulizer two times a day for COPD. Further review of Resident 25's medial record showed the nebulizer treatment was administered on 2/28/23 at 0900 hours. Review of Resident 25's care plan problem addressing a risk for shortness of breath secondary to his disease process revised on 2/7/23, showed to administer budesonide medication as ordered. On 2/28/23 at 0938 and 1027 hours, a nebulizer machine was observed on Resident 25's bedside table. Resident 25's nebulizer tubing was observed to be attached to the nebulizer machine, but part of the nebulizer tubing was touching the floor. Resident 25's nebulizer mask was observed to be placed in a plastic bag dated 2/10/23, inside Resident 25's top drawer. On 2/28/23 at 1028 hours, an interview was conducted with LVN 1. When asked about the process for storing the nebulizer mask and tubing, LVN 1 stated that it should be changed every week, put inside a plastic bag, and dated when it was changed. On 2/28/23 at 1041 hours, a concurrent observation and a follow-up interview was conducted with LVN 1. LVN 1 verified and acknowledged the above findings. LVN 1 further stated the nebulizer tubing should not be touching the floor and it should have been changed for infection control purposes. On 3/1/23 at 1711 hours, an interview was conducted with the IP. The IP was informed about the above findings and stated the nebulizer tubing should not be touching the floor and it should be changed every week for infection control purposes. 7. Medical record review for Resident 28 was initiated on 2/28/23. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's H&P examination dated 9/28/22, showed Resident 28 had the capacity to understand and make decisions. Review of Resident 28's Order Summary Report showed an order dated 9/27/22, to administer ipratropium-Albuterol solution (medications used to treat and prevent symptoms of wheezing) 0.5-2.5(3) mg/3 ml one vial inhale orally every six hours as needed for wheezing and/or SOB. On 2/28/23 at 0929 and 1023 hours, a concurrent observation and interview was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 11 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Resident 28. A nebulizer machine was observed on Resident 28's bedside table. Resident 28's nebulizer tubing was observed not attached to the nebulizer machine and the end port (the part to be connected to the resident's nebulizer machine) was on the floor. Resident 28's nebulizer mask was observed to be placed in a plastic bag dated 1/11/23, inside Resident 28's top drawer. Resident 28 stated she sometimes used it. Residents Affected - Few On 2/28/23 at 1028 hours, an interview was conducted with LVN 1. When asked about the process for storing the nebulizer mask and tubing, LVN 1 stated it should be changed every week, put inside a plastic bag, and dated when it was changed. LVN 1 further stated it should be changed if the nebulizer tubing was on the floor even it was not in use. On 2/28/23 at 1044 hours, a concurrent observation and a follow up interview was conducted with LVN 1. LVN 1 verified and acknowledged the above findings. LVN 1 stated the nebulizer tubing should not be on the floor and the plastic bag was dated 1/7/23. LVN 1 further stated it should have been changed for infection control purposes. LVN 1 was observed discarding the nebulizer mask and tubing in the trash. On 3/1/23 at 1711 hours, an interview was conducted with the IP. The IP was informed about the above findings and stated the nebulizer tubing should not be touching the floor and it should be changed every week for infection control purposes. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the equipment utilized to provide oxygen and nebulizer treatments for three of the 14 final sampled residents (Residents 5, 28, and 403) and four nonsampled residents (Residents 8, 17, 20, and 25) were changed and/or labeled in accordance with the facility's P&P. * The facility failed to ensure Resident 5's nasal cannula and nebulizer mask were labeled with the date when they were changed. * The facility failed to ensure Resident 17's nasal cannula was labeled with the date when it was changed and failed to ensure Resident 17's oxygen concentrator humidifier bottle and plastic bag were changed every seven days as per the facility's P&P. * The facility failed to ensure Resident 20's nebulizer mask was labeled with the date when it was changed and failed to ensure Resident 20's oxygen concentrator humidifier bottle was changed. * The facility failed to ensure Resident 8's nasal cannula and humidifier were changed as per the facility's P&P. In addition, Resident 8's nebulizer mask bag was not labeled with the resident's name as per the facility's P&P. * The facility failed to ensure Resident 403's nasal cannula and nebulizer mask were changed every seven days and labeled with the resident's name and dated. * The facility failed to ensure Residents 25 and 28's nebulizer mask and tubing were stored as per the facility's P&P. These failures posed the risk for resident's equipment to become contaminated which had the potential to negatively affect the resident's medical condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 12 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Findings: Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Departmental Respiratory Therapy - Prevention of Infection revised November 2011 showed the following: Residents Affected - Few - General guidelines: distilled water used in respiratory therapy must be dated and initialed when opened and discarded after 24 hours. - Infection Control Considerations to Oxygen administration: use distilled water for humidification per facility protocol, mark bottle with date and initials upon opening and discard after 24 hours and change the oxygen cannula and tubing every seven days or as needed. - Infection Control Considerations related to Medication nebulizer/continuous aerosols: store the circuit in plastic bag, marked with date and resident's name between uses, and discard the administration set-up every seven days. 1. Medical record review for Resident 5 was initiated on 2/28/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 1/10/23, showed Resident 5 had diagnoses including hypoxemia (a low level of oxygen in the blood). Review of Resident 5's Order Summary Report showed a physician's order dated 1/1/23, to administer oxygen inhalation at two liters per minute via nasal cannula to keep oxygen saturation level greater than 92% or complaint of shortness of breath as needed; and a physician's order dated 2/22/23, to administer ipratropium-albuterol (breathing treatment medication) 0.5-2.5 mg/3 ml inhale orally via nebulizer every six hours as needed for SOB or wheezing (breathing with difficulty and with a whistling sound and shortness of breath). Review of Resident 5's MAR for February 2023 showed Resident 5 was administered ipratropium-albuterol medication on 2/22, 2/25, and 2/26/23. On 2/28/23 at 1025 hours, an observation was conducted in Resident 5's room. Resident 5 was observed lying on bed receiving oxygen therapy via nasal cannula. Resident 5's nebulizer mask was observed inside a plastic bag. Resident 5's nasal cannula and nebulizer mask were not dated. On 2/28/23 at 1036 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 5's nasal cannula and nebulizer mask were not dated. When asked how often Resident 5's nasal cannula and nebulizer mask should be changed, LVN 1 stated it should be changed once a week for infection control. 2. On 2/28/23 at 0912 and 1051 hours, an observation was conducted in Resident 17's room. Resident 17's oxygen concentrator humidifier and plastic bag were observed labeled and dated 2/10/23. Resident 17's nasal cannula stored inside a plastic bag had no date. Medial record review for Resident 17 was conducted on 2/28/23. Resident was admitted to the facility on [DATE]. Review of Resident 17's Physician's Order dated 2/19/23, to administer oxygen inhalation at two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 13 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 liters per minute via nasal cannula as needed to keep oxygen saturation level greater than 92% for SOB. Level of Harm - Minimal harm or potential for actual harm Review of Resident 17's Oxygen Saturation readings showed Resident 17 received oxygen on 2/9 and 2/15/23. Residents Affected - Few On 2/28/23 at 1100 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 17's oxygen concentrator humidifier bottle and plastic bag were dated 2/10/23, and Resident 17's nasal cannula was not dated. When asked how often Resident 17's humidifier, plastic bag, and nasal cannula should be changed, LVN stated it should be changed and dated once a week to prevent infection. 3. Medical record review for Resident 20 was initiated on 2/28/23. Resident was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 4/14/22, showed the resident's diagnoses including COPD. Review of Resident 20's Physician's Order dated 2/5/23, to administer oxygen inhalation at two liters per minute via nasal cannula as needed to keep oxygen saturation level greater than 92% for SOB. Review of Resident 20's Order Summary Report showed a physician's order dated 8/4/22, to administer ipratropium-albuterol solution 0.5-2.5 mg/3 ml one vial inhale orally via nebulizer two times a day for COPD. Review of Resident 20's Oxygen Saturation readings showed Resident 20 received oxygen on 2/6, 2/7, and 2/11/23. On 2/28/23 at 1022 hours, an observation was conducted in Resident 20's room. Resident 20's oxygen concentrator humidifier bottle was observed dated 2/5/23, and Resident 20's nebulizer mask was observed with no date inside a plastic bag. On 2/28/23 at 1029 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 20's oxygen concentrator humidifier bottle was dated 2/5/23, and Resident 20's nebulizer mask was not dated. When asked how often Resident 20's oxygen humidifier bottle and nebulizer mask should be changed, LVN 1 stated it should be changed once a week for infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 14 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide appropriate pain management for one of 14 final sampled residents (Resident 40). Residents Affected - Few * The facility failed to ensure Resident 40 was administered her pain medication promptly after Resident 40 complained of severe pain to her right lower back. The licensed nurses failed to dispense the pain medication which was available in the facility's emergency kit (contains a small quantity of medications that can be dispensed when pharmacy services are not available). This failure resulted in Resident 40's pain left unmanaged and feeling helpless for not receiving her pain medication to manage her severe pain. Findings: Review of the facility's P&P titled Pain Assessment and Pain Management revised 3/2020 showed acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Under Implementing Pain Management Strategies, showed to implement the medication regimen as ordered, carefully documenting the results of the interventions. On 3/1/23 at 1250 hours, an interview was conducted with Resident 40. Resident 40 stated she had right rib pain, and right lower back pain, and her pain level was 7 out of 10 (on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain). Resident 40 stated she had asked for her pain medication at 1200 hours and not yet received her pain medication. Resident 40 stated she asked for the ointment to be applied to her right lower back and her Norco pain medication. Resident 40 stated she was told by the charge nurse that her Norco was not available, and it was pending delivery from the pharmacy. Resident 40 stated she did not understand why she ran out of the pain medication and the licensed nurses could not tell her when her pain medication would become available. Resident 40 stated she felt helpless not knowing when she could get her pain medication. Medical record review for Resident 40 was initiated on 2/28/23. Resident 40 was readmitted to the facility on [DATE]. Review of Resident 40's Order Summary Report showed the following physician's orders dated 2/8/23: - To monitor pain every shift using a 0-10 pain scale as follows: 0 = no pain, 1-3 = mild pain, 4-6 moderate pain, and 7 -10 severe pain; - ibuprofen (used to treat mild to severe pain) 200 mg three tablets by mouth every six hours as needed for neck pain breakthrough pain; - diclofenac sodium (used to relieve joint pain) external gel 1%, apply to the right side rib/hip area three times a day for pain management; - acetaminophen (used to treat mild to moderate pain) 325 mg two tablets by mouth every four hours for mild pain, 1-3 pain level; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 15 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm - acetaminophen extra strength 500 mg two tablets by mouth every six hours for moderate pain, 4-6 pain level; and - Norco (a combination opioid medication used to manage moderate to severe pain) one tablet by mouth every eight hours as needed for severe pain, 7-10 pain level. Residents Affected - Few On 3/1/23 at 1310 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 40 complained of severe right lower back pain and requested for her ointment (diclofenac gel) and Norco pain medication at around 1200 hours. LVN 2 stated she was not able to administer the diclofenac gel because Resident 40 was sitting in her wheelchair, and she needed Resident 40 to be in bed so she could administer the diclofenac gel to the resident's hip area. LVN 2 stated she was waiting for the CNA to assist Resident 40 back to bed. When asked about the Norco pain medication, LVN 2 stated she did not administer the Norco because the facility ran out of her Norco and she was waiting for the pharmacy to deliver the Norco. When asked if she had checked the emergency kit for the availability of the Norco, LVN 2 looked for the emergency kit and verified Norco was available in the emergency kit. LVN 2 stated she was not aware if there was already a pharmacy authorization to get the Norco from the emergency kit. On 3/1/23 at 1315 hours, an interview was conducted with LVN 4. LVN 4 stated she had called the pharmacy earlier regarding the authorization. LVN 4 stated she got the pharmacy authorization to get the Norco pain medication from the emergency kit, and she already informed LVN 2 earlier. On 3/3/23 at 1059 hours, an interview and concurrent medical record review was conducted with the DON and ADON. The DON and ADON verified the above findings. The DON stated as soon as we had the authorization from the pharmacy, the charge nurse should have opened the emergency kit and given the Norco pain medication to Resident 40. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 16 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P, the facility failed to provide the necessary care for one of 14 final sampled residents (Resident 32). Residents Affected - Few * The facility failed to ensure Resident 32's medication and supplement were administered as ordered by the physician on the days the resident left the facility for dialysis (a process of purifying the blood of a person whose kidneys are not working normally). This had the potential for Resident 32 not getting the appropriate doses of medication and supplement as ordered, resulting in health complications. Findings: Review of the facility's P&P titled Medication Administration General Guidelines revised 1/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. It also showed that medications are administered in accordance with written orders of the attending physician. Medical record for Resident 32 was initiated on 2/28/23. Resident 32 was admitted to the facility on [DATE], and readmitted [DATE]. Review of the Order Summary Report showed a physician's orders dated: - 12/19/21, to administer Brilinta (a blood thinner medication to prevent stroke, heart attack, and other heart problems) 90 mg one tablet by mouth two times a day for atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) at 1400 and 2200 hours. - 1/26/22, to administer one scoop of Beneprotein (instant protein powder that supplies the protein needed to help maintain muscles) three times a day with meals at 0800, 1200, and 1800 hours. Review of the Order Summary Report did not show a physician's order to hold or reschedule Resident 32's medications or supplements on dialysis days. Review of Resident 32's Medication Administration Record dated February 2023 showed no documented evidence the Benprotein and Brilinta were administered to the resident on the following dates. The MAR showed code 5 or 9 was recorded on those dates (code 5 = hold/see progress notes and code 9 = other/see progress notes). - Beneprotein one scoop at 1200 hours on 2/1, 2/3, 2/6, 2/8, 2/13, 2/15, 2/17, 2/20, 2/22, 2/24, and 2/27/23; and - Brilinta 90 mg at 1400 hours on 2/1, 2/3, 2/15, 2/22, 2/24, and 2/27/23. Review of the medical record titled Progress Notes dated 2/1, 2/3, 2/6, 2/8, 2/13, 2/15, 2/17, 2/20, 2/22, 2/24, and 2/27/23, showed Resident 32 was at dialysis. On 3/3/23 at 0753 hours, and interview was conducted with CNA 3. CNA 3 stated Resident 32 went to dialysis on Mondays, Wednesdays, and Fridays. CNA 3 further stated Resident 32 was picked up after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 17 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 0900 hours, and returned from dialysis between 1500 to 1530 hours. Level of Harm - Minimal harm or potential for actual harm On 3/3/23 at 1018 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 32 returned from dialysis around 1445 hours. LVN 3 was asked what the chart code 9 on the Medication Administration Record meant, LVN 3 stated that chart code 9 meant to refer to the progress notes. LVN 3 stated the progress notes showed documented evidence Resident 32 was at dialysis. LVN 3 verified there was no physician's order to hold nor reschedule Resident 32's medication and supplement on the days he had dialysis treatments. LVN 3 further stated it should have been clarified with the physician if unable to administer Resident 32's medications or supplements. Residents Affected - Few On 3/3/23 at 1039 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated it should have been clarified with the physician so Resident 32 would not missed his medication and supplement as ordered. Cross reference to F760. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 18 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 14 final sampled residents (Residents 14 and 40). * Resident 40 who had bilateral 1/4 (quarter) side rails in bed was not assessed for risk for entrapment. * Resident 14 who had bilateral 1/4 (quarter) side rails in bed was not assessed for risk for entrapment. This failure posed the risk for injury for Residents 14 and 40 from side rail use. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of side rails, and that the bed dimensions are appropriate for the resident's size and weight. 1. On 3/1/23 at 1250 hours, 3/2/23 at 1153 hours, and 3/3/23 at 0843 hours, Resident 40 was observed in bed, with bilateral side rails elevated. Medical record review for Resident 40 was initiated on 2/28/23. Resident 40 was readmitted to the facility on [DATE]. Review of Resident 40's Order Summary Report showed a physician's order dated 2/9/23, for bilateral 1/4 side rails in bed as enabler for bed mobility. Review of Resident 40's MDS dated [DATE], showed Resident 40 required extensive assistance on one staff for bed mobility. Review of the Bedside Rails Informed Consent and Release dated 2/8/23, showed the risks of using the bed side rails included entrapment in the following ways: through the bars of an individual side rail, through the space between the split side rails, between the side rails and mattress, and between the headboard or footboard, side rails and mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 19 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Side Rails Screening Tool dated 2/8/23, showed the IDT recommended the use of side rails, and Resident 40 was able to hold on the rails during ADL care such as for bed mobility and for turning . Review of Resident 40's plan of care showed a care plan problem addressing the use of bilateral 1/4 side rails as enable to improve mobility and transfers. The approaches/tasks included to assess ability to use side rails on admission, quarterly, and as needed. The IDT was to discuss results and risks and benefits with the resident/family. Further review of Resident 40's medical record did not show documentation Resident 40 was assessed for the risk for entrapment. On 3/3/23 at 1335 hours, when asked about the process for the residents who used the side rails, LVN 4 stated the RN supervisors were responsible for conducting the side rail assessments including the entrapment assessments. When asked to show if Resident 40 was assessed for the risk for entrapment, LVN 4 verified there was none. On 3/3/23 at 1413 hours, an interview with the MT and DON. The MT stated the maintenance department was responsible for the bed inspection. The MT and DON failed to show an entrapment assessment was conducted with Resident 40. Cross reference to F909, example #1. 2. On 2/28/23 at 0841 hours, 3/1/23 at 1015 hours, and 3/3/23 at 0902 hours, Resident 14 was observed in bed with bilateral side rails elevated. Medical record review for Resident 14 was initiated on 2/28/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed a physician's order dated 1/12/23, to provide bilateral 1/4 side rails up when in bed as an enabler for bed mobility. Review of Resident 14's MDS dated [DATE], showed Resident 14 required extensive assistance with two persons assistance for bed mobility. Review of Resident 14's medical record failed to show an assessment was completed for the risk of entrapment prior to use of the bilateral side rails. On 3/3/23 at 1322 hours, an observation and concurrent interview was conducted with the IP nurse. The IP nurse verified Resident 14 was in bed with bilateral 1/4 side rails elevated. On 3/3/23 at 1335 hours, an interview and concurrent medical record review for Resident 14 was conducted with LVN 4. When asked if Resident 14 was assessed for risk for of entrapment, LVN 4 was unable to provide the documentation of Resident 14's entrapment assessment. On 3/3/23 at 1415 hours, an interview was conducted with the MT and DON. The MT and DON acknowledged Resident 14 was not assessed for risk of entrapment prior to the side rails use. Cross reference to F909, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 20 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 43) and three nonsampled residents (Residents 9, 11, and 30). * Resident 43's Tramadol (a narcotic pain medication) Controlled Medication Count Sheet did not match Resident 43's MAR. * Resident 9's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Medication Count Sheet did not match Resident 9's MAR. * Resident 11's hydrocodone-acetaminophen Controlled Medication Count Sheet did not match Resident 11's MAR. * The facility failed to ensure Resident 30's biotin (a supplement) was administered as ordered by the physician. These failures posed the risk for diversion of controlled medications and possible health complications due to not administering a medication as prescribed. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Medication Administration General Guidelines revised January 2017, under the section for Administration, showed medications are administered in accordance with written orders of the attending physician. Under the Documentation section showed the individual who administered the medication dose records the administration on the resident's MAR after the medication pass is completed. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. In no case, the individual who administers the medications reports off-duty without first recording the administration of any medication. 1. On 3/1/23 at 1552 hours, review of Residents 9, 11, and 43's Controlled Medication Count Sheets and MARs was conducted with LVN 5. a. Review of Resident 43's Tramadol Controlled Medication Count Sheet showed Resident 43 was administered Tramadol 50 mg one tablet on 1/4/23 at 0500 hours, and 1/25/23 at 2000 hours. Review of Resident 43's January 2023 MAR failed to show documentation of administration of Tramadol on 1/4/23 at 0500 hours, and 1/25/23 at 2000 hours. LVN 5 verified Resident 43's Controlled Medication Count Sheet did not match Resident 43's MAR for January 2023. Medical record review for Resident 43 was initiated on 3/1/23. Resident 43 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 43's Order Summary Report showed a physician's order dated 1/19/23, to administer Tramadol 50 mg one tablet by mouth every six hours as needed for moderate to severe pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 21 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. Review of Resident 9's hydrocodone-acetaminophen Controlled Medication Count Sheet showed Resident 9 was administered hydrocodone-acetaminophen 10-325 mg one tablet on 1/29/23 at 0000 hours, 2/3/23 at 1600 hours, and 2/11/23 at 0900 hours. Review of Resident 9's January 2023 MAR failed to show documentation of administration of hydrocodone-acetaminophen on 1/29/23 at 0000 hours. LVN 5 verified Resident 9's Controlled Medication Count Sheet did not match Resident 9's MAR for January 2023. Review of Resident 9's February 2023 MAR failed to show documentation of administration of hydrocodone-acetaminophen on 2/3/23 at 1600 hours, and 2/11/23 at 0900 hours. LVN 5 verified Resident 9's Controlled Medication Count Sheet did not match Resident 9's MAR for February 2023. Medical record review for Resident 9 was initiated on 3/1/23. Resident 9 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Resident 9's Order Summary Report showed a physician's order dated 1/24/23, to administer hydrocodone-acetaminophen 10-325 mg one tablet by mouth every four hours as needed for severe pain. c. Review of Resident 11's hydrocodone-acetaminophen Controlled Medication Count Sheet showed Resident 11 was administered hydrocodone-acetaminophen one tablet on 1/30/23 at 2000 hours, 2/1/23 at 0500 hours, 2/1/23 at 1100 hours, and 2/11/23 at 0600 hours. Review of Resident 11's January 2023 MAR failed to show documentation of administration of Resident 11's hydrocodone-acetaminophen on 1/30/23 at 2000 hours. LVN 5 verified Resident 11's Controlled Medication Count Sheet did not match Resident 11's MAR for January 2023. Review of Resident 11's February 2023 MAR failed to show documentation of administration of Resident 11's hydrocodone-acetaminophen on 2/1/23 at 0500 hours, 2/1/23 at 1100 hours, and 2/11/23 at 0600 hours. However, Resident 11's MAR for February 2023 showed Resident 11 was given hydrocodone-acetaminophen one tablet on 2/1/23 at 2100 hours. LVN 5 verified Resident 11's Controlled Medication Count Sheet did not match Resident 11's MAR for February 2023. Medical record review for Resident 11 was initiated on 3/1/23. Resident 11 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 11's Order Summary Report showed a physician's order dated 10/20/22, to administer hydrocodone-acetaminophen 5-325 mg one tablet by mouth every six hours as needed for moderate to severe pain. On 3/1/23 at 1659 hours, an interview and concurrent medical record review of Residents 9, 11, and 43's Controlled Medication Count Sheet and MAR was conducted with the DON. The DON verified the above findings. When asked regarding the controlled drug documentation, the DON stated the nurse should sign the Controlled Medication Count Sheet and MAR right away when the controlled drug was administered. 2. On 3/2/23 at 0826 hours, a medication administration observation was conducted with LVN 3. LVN 3 prepared and administered Resident 30's medications. However, LVN 3 failed to administer Resident 30's biotin gummy supplement as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 22 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 30 was initiated on 3/2/23. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Order Summary Report showed a physician's order dated 2/15/22, to administer Biotin Capsule 1000 mcg one gummy by mouth one time a day for supplement. Residents Affected - Few On 3/2/23 at 1157 hours, an interview was conducted with LVN 3. LVN 3 verified Resident 30's biotin was not administered. LVN 3 stated Resident 30's biotin supply did not match the dose in Resident 30's physician's order and Resident 30's biotin gummy medication was not available in the facility's house supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 23 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 32) was free from the significant medication errors when the facility failed to administer Resident 32's Brilinta (a blood thinner medication to prevent stroke, heart attack, and other heart problems) during dialysis (a process of purifying the blood of a person whose kidneys are not working normally) days and failed to ensure a physician's order was obtained to hold or reschedule the blood thinner medication as ordered on dialysis days. This failure had placed Resident 32 at risk for medical complications. Residents Affected - Few Findings: Review of the facility's P&P titled Medication Administration General Guidelines revised 1/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. The P&P also showed medications are administered in accordance with written orders of the attending physician. Medical records for Resident 32 was initiated on 2/28/23. Resident 32 was admitted to the facility on [DATE], and readmitted [DATE]. Review of the Order Summary Report showed a physician's orders dated 12/19/21, to administer Brilinta (a blood thinner medication to prevent stroke, heart attack, and other heart problems) 90 mg one tablet by mouth two times a day for atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) at 1400 and 2200 hours. Review of the Order Summary Report did not show a physician's order to hold or reschedule Resident 32's medication on dialysis days. Review of Resident 32's MAR dated February 2023 showed Brilinta 90 mg at 1400 hours on 2/1, 2/3, 2/15, 2/22, 2/24, and 2/27/23, were documented with code 5 or 9. The MAR showed code 5 = hold/see progress notes and code 9 = other/see progress notes. Review of the Progress Notes dated 2/1, 2/3, 2/15, 2/22, 2/24, and 2/27/23, showed Resident 32 was at dialysis. Further review of Resident 32's medical record failed to show documentation Brilinta 90 mg was administered twice a day as ordered by the physician on 2/1, 2/3, 2/15, 2/22, 2/24 and 2/27/23. The medical record also failed to show Resident 32's physician was notified that Resident 32 did not receive his medication as ordered. On 3/3/23 at 0753 hours, and interview was conducted with CNA 3. CNA 3 stated Resident 32 went to dialysis on Mondays, Wednesdays, and Fridays. CNA 3 further stated Resident 32 was picked up after 0900 hours, and returned from dialysis between 1500 to 1530 hours. On 3/3/23 at 1018 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 32 returned from dialysis around 1445 hours. LVN 3 was asked what code 9 on the MAR meant, LVN 3 stated code 9 meant to refer to progress notes. LVN 3 stated the progress notes showed Resident 32 was at dialysis. LVN verified there was no physician's order to hold nor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 24 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reschedule Resident 32's medication on the days he had dialysis treatments. LVN 3 further stated it should have been clarified with the physician if unable to administer Resident 32's medication. On 3/3/23 at 1039 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated it should have been clarified with the physician so that Resident 32 would not missed his medication as ordered. Event ID: Facility ID: 555718 If continuation sheet Page 25 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to store and label the medications properly and failed to discard the expired supplies. * Medication Cart 1 had two opened and unlabeled Chloraseptic spray bottles (a medication to treat sore throat or mouth) without resident's name and/or room number. This had the potential for the medication to be used for other residents. * The facility failed to store Resident 17's artificial tears bottle (a medication to treat dry eyes) in a safe manner. This had the potential for the medication to be used for other residents. * Medication room [ROOM NUMBER] drawer had expired port-a-cath needles. This had the potential for use of expired supplies. Findings: Review of the facility's P&P titled Storage of Medication revised [DATE] showed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Review of the facility's P&P titled Preparation and General Guidelines for Medication Administration revised date [DATE] showed medication supplied for one resident are never administered to another resident. 1. On [DATE] at 1552 hours, an inspection of Medication Cart 1 was conducted with LVN 5. Two opened and unlabeled Chloraseptic spray bottles were observed inside Medication Cart 1. LVN 5 verified the two Chloraseptic bottles were opened and had no resident name and/or room number. When asked who the Chloraseptic medication bottles belonged to, LVN 5 stated the Chloraseptic medications belonged to Resident 17. LVN 5 acknowledged it should have been labeled with Resident 17's name and room number. Medical record review for Resident 17 was initiated on [DATE]. Resident was admitted to the facility on [DATE]. Record review of Resident 17's Order Summary Report showed a physician's order dated [DATE], to administer Phenol (Chloraseptic) aerosol solution 1.4% apply to throat/mouth topically every six hours for mucositis (a painful irritation of the lining of mouth or intestinal tract). Review of Resident 17's MAR for February 2023 showed Resident 17 received Phenol medication daily every six hours. 2. On [DATE] at 0826 hours, a medication administration observation was conducted with LVN 3. Resident 17's artificial tears bottle was opened and unlabeled. LVN 3 acknowledged Resident 17's artificial tears bottle should have been labeled with the resident's name and/or room number. Medical record review for Resident 17 was initiated on [DATE]. Resident 17 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 26 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 17's Order Summary Report showed a physician's order dated [DATE], to administer artificial tears solution 0.2-0.2-1% instill one drop to left eye two times a day for left eye redness. Residents Affected - Few Review of Resident 17's MAR for February 2023 showed Resident 17 received the artificial tears medication two times daily. 3. On [DATE] at 0922 hours, an inspection of Medication room [ROOM NUMBER] was conducted with the ADON. Two port-a-cath needles expired on [DATE], was observed in Medication room [ROOM NUMBER] drawer. The ADON acknowledged the expired needles should have been discarded. On [DATE] at 0802 hours, an interview was conducted with the DON. When asked regarding Chloraseptic and artificial tears OTC supplies, the DON stated it was used for single resident and should be labeled with the resident's name and or/room number, and any expired supply should be disposed and replaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 27 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility P&P, and facility document review, the facility failed to ensure the puree recipes were followed during the puree procedure of the residents food. This failure posed the risk for the inconsistent puree product which could alter the quality and nutrient content of the puree food for seven of 49 residents who received a puree diet. Findings: Review of the facility's P&P titled Puree Procedure (undated) showed to prepare regular item according to the recipe. The P&P also showed to place one portion of regular texture item in the blender or Robot Coupe/food processor, add additional appropriate liquid for the original recipe, and start with minimal amount of fluid and increase as needed to achieve puree consistency. 1. Review of the Simple Steamed Cabbage, Simply Good from Food.com dated 11/10/22, showed the handwritten instructions for puree as follows: take a four-ounce serving of cabbage and place in food processor; puree until smooth (add vegetable stock if needed); thickened with one teaspoon or one tablespoon at a time; pudding-like consistency. On 3/1/23 at 1257 hours, a concurrent observation and interview was conducted with [NAME] 3. During the puree procedure observation, [NAME] 3 stated he was preparing the puree foods for the dinner meal. [NAME] 3 did not have a recipe for the puree foods that he was preparing. [NAME] 3 stated he was preparing seven portions of puree steamed squash. [NAME] 3 placed four ounces per serving into the blender and added an unmeasured quantity of vegetable-based broth then blended the product. The puree squash had a liquid consistency. [NAME] 3 placed the blended squash in a circular metal bowl. [NAME] 3 placed the rest of the squash in the blender and added an unmeasured quantity of vegetable-based broth and blended the product. The puree squash had a liquid consistency. [NAME] 3 added the blended squash to the circular metal bowl. [NAME] 3 stated the consistency of the puree food should be pudding-like consistency. [NAME] 3 stated he was using a two-tablespoon scoop for the thickener powder. [NAME] 3 added two scoops of thickener powder to the blended squash and then whisked the product. [NAME] 3 continued to add the thickener powder until the product reached a pudding-like consistency. [NAME] 3 added a total of seven scoops (14 tablespoons) of thickener powder to the squash. When [NAME] 3 completed preparing the puree squash, [NAME] 3 placed the puree squash in a small metal pan and covered the top with a plastic wrap, then placed the puree squash in an oven with a temperature of 180 degrees Fahrenheit. On 3/2/23 at 0811 hours, an interview was conducted with the RDN. The RDN stated she approved the menus which included the recipes for menu items. The RDN confirmed the recipe for steamed cabbage included handwritten instructions for the puree process written by the DSN. The RDN confirmed the written puree process stated to add vegetable broth if needed after the cabbage had been blended. The RDN confirmed the vegetables had a high water content and most vegetables could be pureed without adding liquid. Cross reference to F804. 2. Review of the Roast Beef (Puree) recipe from DRIVE dated 3/1/23, showed recipe scaled to two pounds, 13 ounces (3 x batch). Procedure: prepare recipes according to recipe. In food processor, add beef and hot stock. Process for two to three minutes, or until smooth. CCP-hold hot (140 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 28 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Fahrenheit or above) for service. Portion: use as directed by menu service plan. Level of Harm - Minimal harm or potential for actual harm On 3/1/23 at 1312 hours, during the pureed food preparation, a concurrent observation and interview was conducted with [NAME] 3. When asked how many servings of mechanically altered roast beef he was preparing, without having a recipe to refer to, [NAME] 3 stated he was preparing a total of 18 servings, about six pounds of roast beef for the puree and mechanical soft textures. [NAME] 3 placed an unmeasured amount of roast beef into the Robot Coupe/food processor and blended the meat until a ground consistency was achieved. [NAME] 3 then placed an unmeasured quantity of the ground meat in a steamtable pan and stated the meat was for mechanical soft diets. When asked how much roast beef was left for the puree meat, [NAME] 3 stated half of the meat was for puree, a total of seven puree servings. [NAME] 3 added an unmeasured quantity of ground roast beef to the blender. When asked how much roast beef he added to the blender, [NAME] 3 stated, Five cups. Using a four-ounce ladle, [NAME] 3 added three partially full ladles of beef broth to the blender. [NAME] 3 stated he made the beef broth by mixing five tablespoons of beef base with two gallons of water. [NAME] 3 then added two more partially full ladles of beef broth to the ground meat in the blender. The meat and broth mixture were blended, then [NAME] 3 added two tablespoons of thickener, mixed the product, and added two additional tablespoons of thickener. [NAME] 3 put the finished pureed roast beef into the holding oven at 180 degrees Fahrenheit. During the pureed food preparation, the cook did not refer to a recipe or puree procedure. Residents Affected - Few On 3/2/23 at 0811 hours, an interview was conducted with the RDN. The RDN stated she approved the menus which included the recipes for menu items. The RDN confirmed the recipe for the puree roast beef was not for seven servings and she would have to adjust the recipe to reflect the servings sizes that were appropriate for the facility size. The RDN confirmed the goal for pureed food was to achieve the correct consistency using a minimal amount of liquid so thickener was not needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 29 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility P&P, and facility document review, the facility failed to ensure the puree food was prepared to preserve nutritive value as evidenced by: Residents Affected - Few * Excess water and thickener were added to the puree vegetables. * Puree vegetables were cooked more than three hours prior to meal service and held in a hot oven. These failures posed the risk for not meeting the nutritional needs of seven residents who received a puree diet. Findings: Review of the professional reference titled https://www.healthline.com/nutrition/cooking-nutrient-content dated 11/7/19, showed the reference indicated, . The following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium . Review of the Mealtimes showed the following: breakfast at 0705, lunch at 1130, and dinner at 1705 hours. On 3/1/23 at 0818 hours, an interview was conducted with [NAME] 3. When asked to observe the puree process, [NAME] 3 stated puree foods for lunch was completed. [NAME] 3 stated he started preparing the puree food for lunch time at 0800 hours. [NAME] 3 showed the puree breaded cod and puree cabbage in two small pans placed in a large pan on the stove above boiling water. On 3/1/23 at 1257 hours, a concurrent observation and interview was conducted with [NAME] 4. During the puree procedure observation, [NAME] 4 stated he was preparing the puree foods for dinner time. [NAME] 4 stated he was preparing seven portions of steamed squash. [NAME] 4 placed four ounces per serving into the blender, added vegetable-based broth, and blenderized the mixture. Then [NAME] 4 placed the blenderized squash in a circular metal bowl and placed the rest of the squash in the blender, added a little vegetable-based broth, and blenderized the mixture. Then [NAME] 4 added the blenderized squash to the circular metal bowl. [NAME] 4 was asked what was the consistency of the puree food and stated pudding like consistency. [NAME] 4 stated he was using a two tablespoons scoop for the thickener powder. [NAME] 4 added two scoops of thickener powder to the blenderized squash and then whisked. At the end of the puree process, [NAME] 4 used a total of seven scoops of thickener powder to reach the consistency of puree. [NAME] 4 stated after some time, the vegetable would water down that was why he added extra thickener. When completed preparing the puree squash, [NAME] 4 placed the puree squash in a small metal pan and covered with saran wrap, then placed in an oven with temperature of 180 degrees Fahrenheit. On 3/2/23 at 0829 hours, an interview was conducted with the RDN. When asked how much liquid should be added when the puree vegetable was prepared, the RDN stated the vegetable with a higher liquid content should not be added with a lot of liquid or thickener. When asked what time should the puree foods be prepared and the RDN stated the less amount of time, the better, and within reason as close to tray line as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 30 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and facility document review, the facility failed to ensure the entree substitutes offered were of equal nutritive value when grilled cheese sandwiches were not equal in protein content to the main entrée. This failure had the potential of not meeting the resident's nutritional needs. Findings: On 3/1/23 at 1108 hours, during the lunch tray line observation and concurrent interview was conducted with [NAME] 3. [NAME] 3 was observed preparing a grilled cheese sandwich which consisted of two pieces of white bread and three slices of yellow cheese. [NAME] 3 stated he was preparing a grilled cheese sandwich as a meal alternate. Review of the facility document titled Nutrition Facts Sheet -US Beer Battered Fresh Cod Nutritional Facts dated 3/1/23, showed one serving of the beer battered fresh cod used to make the crispy cod sandwich entrée served for the lunch meal on 3/1/23, provided 24 grams of protein. Review of the cheese package used to make the grilled cheese sandwich entrée alternate served for the lunch meal on 3/1/23, showed Great Lakes Cheese American Pasteurized Process Cheese Nutrition Facts: serving size two slices (28 grams) provided five grams of protein. Therefore, three slices of the American Pasteurized Process Cheese used to make the grilled cheese sandwich entrée alternate was equivalent to 7.5 grams of protein which was 16.5 grams of protein less than the beer battered fresh cod used to make the crispy cod sandwich entrée. On 3/2/23 at 0832 hours, an interview was conducted with the RDN. The RDN was shown the nutrition facts label for the main entrée, beer battered fresh cod used to make the crispy cod sandwich and the nutrition facts label for the alternate entrée, Great Lakes American Pasteurized Process Cheese used to make the grilled cheese sandwich. The RDN verified the protein value of the alternative option was not equal to the protein provided in the main entrée. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 31 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the proper hand washing was performed when preparing food. * The facility failed to ensure the wiping cloths used to sanitize the kitchen surfaces were stored in the sanitizing solution. * The facility failed to ensure the use of a cool down procedure for Time/Temperature Control for Safety Foods for the food that required time and temperature controls to limit the growth of pathogens. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the food items in the freezer was properly labeled. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the use hair restraints was implemented to the dietary staff working in the kitchen. * The facility failed to ensure the backflow prevention of two food preparation sinks was properly maintained. * The facility failed to ensure the food service utensils were in good repair. * The facility failed to ensure one food cart was clean. * The facility failed to ensure the knife rack was clean. * The facility failed to ensure the cleaning equipment was stored properly. These failures had the potential to expose 46 facility residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/1/23, showed 46 of 49 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022 Section 2-301.14, food employees shall clean their hands before donning gloves to initiate a task that involves working with food. On 2/28/23 at 0830 hours, a concurrent observation and interview with the NSD was conducted. The TA was observed preparing salads. The TA was observed to change his gloves twice without performing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 32 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm handwashing between changing his gloves. The NSD verified the finding and stated the TA should perform handwashing between glove changes. 2. Review of the facility's P&P titled Sanitizing Red Buckets dated 1/2022 showed to keep the wiping cloths stored in bucket with sanitizer solution when not being used. Residents Affected - Some According to the USDA Food Code 2022 Section 3-304.14 Wiping Cloths, Use Limitation . (B) Cloths in-use for wiping counters and other surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114 . On 3/1/23 at 0902 hours, a concurrent observation and interview was conducted with the NSD. Three wiping cloths used to sanitize the kitchen surfaces were observed in a red sanitizing bucket. The red sanitizing bucket was not large enough to submerge three wiping cloths in the sanitizing solution. One wiping cloth was not submerged in the sanitizing solution. The NSD verified the finding and stated all wiping cloths should be submerged in the sanitizing solution. The NSD added only two rags should be stored in the red sanitizing bucket. 3. Review of the facility's P&P titled Food Safety Management System, C-23 Cooling and Chilling dated 4/1/22 showed cooling and chilling temperature must be taken with a calibrated thermometer and recorded on the HACCP Cooling and Chilling log. According to the USDA Food Code 2022, Section 3-501.14 Cooling, (B) Time Temperature for Safety Food shall be cooled within four hours to five degrees C (Celsius) 41 degrees F (Fahrenheit) or less if prepared from ingredients at ambient temperature .such as canned tuna. On 3/1/23 at 0908 hours, an interview was conducted with [NAME] 1. [NAME] 1 was asked to explain the facility's cooling process when preparing salads from ambient food. [NAME] 1 stated she used tuna from the dry storage room. After mixing the ingredients with the tuna, [NAME] 1 stated she took the temperature and placed the tuna salad in the refrigerator. [NAME] 1 was asked to show the cooling monitor log for the ambient foods prepared. [NAME] 1 was unable to provide a record of a cooling log. On 3/1/23 at 0908 hours, an interview was conducted with the NSD. The NSD verified the finding and stated we need to put a cooling monitor log in place. 4. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact and utensils shall be clean to sight and touch . On 2/28/23 at 1028 hours, a concurrent observation and interview was conducted with the MT. An observation of the ice machine showed a rough black substance on the inside near the ice chute. The MT verified the finding and stated the surface was not smooth and he was unsure of what the substance was. 5. Review of the facility's P&P titled Labeling and Dating dated 1/2022 showed all foods are labeled, dated, and securely covered and use-by dates are monitored and followed. On 2/28/23 at 0806 hours, during the initial tour of kitchen with the NSD, an observation of the freezer showed three five-pound lamb [NAME], one 25 pound top round, two bags of sausage patties, one bag of tatter tots, two bags of onion rings, and one five pound ground beef were not dated. The NSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 33 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some verified the foods listed above were not dated and stated the person who had put the food away should label and date the food. 6. Review of the facility's P&P titled Air Drying of dishes, equipment, and utensils undated showed dishware is stored in a clean, dry location and not exposed to splash, dust, or other contamination, and covered or inverted. According to the USDA Food Code 2022 Section 4-901.11 Equipment and Utensil, Air Drying required, after cleaning and sanitizing, equipment and utensils: (A) shall be air dried . On 2/28/23 at 0806, during the initial tour of kitchen with the NSD, the food preparation equipment that had just been washed in the manual dishwashing sink were observed stacked in a drying area, measuring approximately four feet in length by three feet in width. The NSD verified the findings and stated no food preparation equipment should be stacked while air drying. The NSD stated they had a separate rack that the staff could use to air dry. On 3/1/23 at 0854 hours, a concurrent observation and interview was conducted with the NSD. An observation of Dishwasher 2 storing clean dishware was conducted. Dishwasher 2 stacked the clean, wet plates and bowls on a metal table near the dish machine. The NSD confirmed all resident dishware should be air dried. 7. According to the USDA Food Code 2022 Section 2-402.11 Effectiveness, (A) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils . On 2/28/23 at 1424 hours, a concurrent observation and interview was conducted with the NSD. Dishwasher 1 was observed with a beard not covered with a hair restraint. The NSD verified the finding and stated Dishwasher 1 needed a beard covering. On 3/1/23 at 1120 hours, a concurrent observation and interview was conducted with the NSD. During meal service, Cooks 1 and 2's hair were not completely covered with the hair restraint. The NSD verified the findings and stated hair should be completely covered with the hair restraint. 8. According to the USDA Food Code 2022 Section 5-202.13 Backflow prevention, Air Gap, an air gap between the water supply inlet and flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm. On 2/28/23 at 1046 hours, a concurrent observation and interview was conducted with the FSC. An observation of the drainpipe from two food preparation sinks was conducted. No air gap was visible for both food preparation sinks. When asked about the lack of an air gap, the FSC stated the plumbing went directly into the wall and did not have an air gap. 9. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. On 2/28/23 at 0806 hours, during the initial tour of kitchen with the NSD, three white rubber (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 34 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some spatulas were observed to be chipped. The NSD verified the finding and stated the spatulas needed replacement. 10. According to the USDA Food Code 2022 Section 4-601.11 Equipment, food-contact surfaces, nonfood-contact surfaces and utensils, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. On 2/28/23 at 1208 hours, a concurrent observation and interview was conducted with the RDN. During the meal observation, one of five food carts was observed with a thick, crusty black residue along the bottom of cart which came off when scaped. The rubber handle of the food cart was worn exposing metal with a brown residue which resembled rust. The RDN verified the findings and agreed the food cart needed washing. On 2/28/23 at 1446 hours, an interview was conducted with the NSD. The NSD stated there was no cleaning schedule for the food carts but were periodically cleaned. 11. According to the USDA Food Code 2022 Section 4-602.13 Nonfood-contact surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. On 2/28/23 at 1051 hours, during the initial tour of kitchen with the NSD, an observation of the knife rack was conducted. Three knives were seen hanging from the knife rack mounted on the wall. The knife rack magnetic strip had a brown substance which resembled rust. The NSD verified the findings and stated the magnetic strip of the knife rack needed replacement. 12. According to the USDA Food Code 2022 Section 6-501.113, Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: .(B) Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. On 2/28/23 at 0806 hours, during the initial tour of kitchen with the NSD, an observation of the chemical room showed a broom was on the floor. The NSD stated the broom should not be on the floor, the broom should be hung on the broom rack, and the chemical room door should be locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 35 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and facility document review, the facility failed to implement their Quality Assessment and Assurance (QA&A) plan of action. There was no documentation to show the facility was monitoring the effects of the corrective action plans to identify if they had achieved and sustained the improvement for the repeated deficient practices cited at F698 and F812 in accordance with their POC for an abbreviated survey completed on 12/9/19. This had the potential to affect the quality of care for all the residents in the facility. Findings: On 3/3/23 at 1605 hours, an interview and concurrent facility document review was conducted with the Administrator. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 12/9/2019, showed the following deficient practices cited: a. For F698 related to the medications held for the residents receiving dialysis care in the facility, the POC included the following: * Medication orders for all residents being admitted with dialysis treatment order would be reviewed by the admitting nurse upon admission and verified by the DON or designee. * Adjusted medication administration time order would be obtained from the MD to ensure that medications would be given to the resident according to their dialysis days. * The DON or designee would monitor clinical record to review all admission orders for dialysis residents 24 hours after admission and 24 hours after every new medication order to ensure that medications were being given timely during dialysis days to ensure compliance is sustained and deficient practice does not occur. *All findings would be reported to the QA&A and carried over to the quarterly QAPI. b. For F812 related to labeling and dating food in the kitchen, the POC included the following: * All kitchen staff would have to correctly answer the question-and-answer test titled Labeling and Dating Quiz. This test would be required for kitchen staff and to be given by the Dietary Director of designee monthly for the next three months and quarterly thereafter. * To ensure this deficient practice does not recur, the Dietary Director or designee would check labels and dates daily during their shift and verified by the RD or designee. Weekly checks by the RD or designee would be conducted. *All findings would be reported to the QA&A and carried over to the quarterly QAPI. The Administrator failed to show documented evidence of the question-and-answer tests administered to the kitchen staff, or the daily and weekly checks by the RD or designee, and documentation of any findings that were presented to the quarterly QAPI meeting in relation to F812 POC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 36 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm On 3/3/23 at 1700 hours, an interview and medical record review was conducted with the DON. The DON showed the progress notes to show the facility had verified the medications for the resident receiving dialysis care. When asked if the DON presented her findings to the quarterly QAPI meeting in relation to

F698 POC, the DON answered no. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 37 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. On 3/2/23 at 0826 hours, RNA 1 was observed assisting Resident 16 with meals. RNA 1 was observed standing over Resident 16 and cutting the resident's donut. Then RNA 1 sat in front of Resident 7 and fed the resident. RNA 1 was not observed performing hand hygiene before and after assisting each resident with meals. Residents Affected - Few On 3/2/23 at 0828 hours, RNA 1 was observed standing up, went over to Resident 16, and cut up Resident 16's food. Then RNA 1 was observed sitting in front of Resident 7 and fed the resident. RNA 1 was not observed performing hand hygiene before and after assisting each resident with meals. On 3/2/23 at 0828 hours, RNA 1 was observed standing up, went over to Resident 16, and offered food to Resident 16's. Then RNA 1 was observed sitting in front of Resident 7 and fed Resident 7. RNA 1 was not observed performing hand hygiene before and after assisting each resident with meals. On 3/2/23 at 0837 hours, RNA 1 was observed standing up, went over to Resident 16, and offered food to Resident 16. Then RNA 1 was observed sitting in front of Resident 7 and fed the resident. RNA 1 was not observed performing hand hygiene before and after assisting each resident with meals. On 3/2/23 at 1437 hours, an interview was conducted with RNA 1. RNA 1 verified the findings. RNA 1 verified she was assisting two residents at the same time for feeding. RNA 1 stated she was feeding Resident 7 and also cuing and assisting Resident 16 with her food. RNA 1 verified she did not wash or sanitize her hands before and after assisting each resident with meals. On 3/2/23 at 1540 hours, an interview was conducted with the DSD. The DSD stated the staff should have performed hand hygiene before and after assisting each resident with meals. Cross reference to F550, example #2. 4. On 2/28/23 at 0922 hours, 3/1/23 at 0930 hours, 3/2/23 at 1106 hours, and 3/3/23 at 0821 hours, Resident 403 was observed in bed with padded side rails. However, the side rail pads were observed porous with tears, holes, and fraying edges. On 3/3/23 at 1322 hours, an observation for Resident 403 and concurrent interview was conducted with the IP. The IP verified the pads used for Resident 403's side rails were porous with tears, holes, and fraying edges. The IP verified the padding could not be cleaned and stated they needed to be replaced right now. Based on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the licensed nurse performed hand hygiene during wound care treatment for Resident 28. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when three dusty fans were in use in the clean linen area and empty water bottle was in the clean linen area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 38 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure RNA 1 performed hand hygiene when assisting meals between two residents (Residents 7 and 16). * The facility failed to ensure the pads used on the bed side rails for one of 14 residents (Resident 403) were cleanable and were not porous, torn and frayed. Residents Affected - Few These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents. Findings: Review of the facility's P&P titled Handwashing/ Hand Hygiene revised date 8/2019 showed to use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations: - before and after direct contact with residents; - before handling clean or soiled dressings, gauze pads, etc; - after handling used dressings, contaminated equipment, etc; - after removing gloves; and - before and after assisting a resident with meals. 1. Review of Resident 28's Order Summary Report showed an order dated 3/1/23, to cleanse the sacral scar tissue with skin redness around with normal saline solution (NSS), pat dry, apply Calazime (a cream used to treat skin irritation) cream, and cover with a dry dressing and Optifoam (a foam dressing that is waterproof) dressing daily. On 3/1/23 at 1006 hours, a wound care observation for Resident 28 was conducted with the Treatment Nurse. The Treatment Nurse was observed cleaning Resident 28's sacral scar tissue with normal saline (a solution of salt and water) solution, pat dried with a clean gauze, and took the measurements of the sacral wound. The Treatment Nurse proceeded to change gloves without washing her hands and was observed applying Calazime cream to Resident 28's sacral scar tissue. Then Treatment Nurse changed gloves without washing her hands and applied a clean gauze and Optifoam dressing to the sacral scar tissue area. On 3/1/23 at 1033 hours, the Treatment Nurse was informed of the observations during wound care treatment for Resident 28. The Treatment Nurse acknowledged the above findings and further stated washing her hands after removing gloves was important for infection control purposes; however, she was not sure about the facility's policy of washing hands when changing of gloves. On 3/1/23 at 1043 hours a follow-up interview was conducted with the Treatment Nurse. The Treatment Nurse stated as per the facility's policy, she should wash her hands when changing gloves. On 3/2/23 at 0740 hours, an interview was conducted with the DON. The DON was informed of the above findings. The DON acknowledged and stated hand hygiene should be performed when changing gloves as per the facility's policy. The DON further stated it was the best practice to wash hands in between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 39 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 changing of gloves to prevent the spread of bacteria. Level of Harm - Minimal harm or potential for actual harm 2. Review of the facility's P&P titled Fan Ventilation Cleaning undated showed it is the facility's policy to use the fans in the laundry processing areas to prevent cross-contamination (transfer of harmful bacteria from one person, object, or place to another) of clean linens from air blowing from soiled processing areas (for example, the ventilation should not flow from soiled processing areas to clean laundry areas). Further review of the facility's policy showed the fans are cleaned twice a week or as needed. Residents Affected - Few Review of the facility's P&P titled Employee Hygiene Guidelines for personal food and beverage dated 2/23 showed that it is the facility's policy for the food and beverage items to remain at a distance from general clean work areas. Further review of the facility's policy showed there are designated places for personal food and beverage items. Review of the facility's document titled Bi-weekly (occurring every two weeks) fan cleaning log sheet Dryer Room undated showed no documented evidence of cleaning the fans used in the clean laundry area. On 3/1/23 at 0755 hours, a laundry area inspection was conducted with the housekeeping staff. a. Three fans were observed in use with accumulated dust on the grill metal cover and blade of the fans in the clean laundry area. One fan was observed on the wall above the clean linen folding area, one fan was observed on top of a covered cabinet, and the other fan was observed on the wall above the clean linen area. b. An empty water bottle was observed on the counter while the laundry staff was folding clean linens. On 3/1/23 at 0830 hours, an interview was conducted with the Laundry Supervisor. When asked who was responsible for cleaning of the fans in the clean laundry area, the Laundry Supervisor stated the maintenance cleaned the fans three times a week, bu he was not sure if the maintenance kept a cleaning log. When asked about the empty water bottle on the counter of the folding area, the Laundry Supervisor verified and further stated it should not supposed to be there for infection control purposes. On 3/1/23 at 0925 hours, a concurrent observation and interview was conducted with the Facility Services Coordinator and Maintenance Technician. The Facility Services Coordinator stated the fans used in the clean laundry area were cleaned monthly; however they did not have a cleaning log. The Facility Services Coordinator and Maintenance Technician verified and acknowledged the above findings. On 3/1/23 at 0957 hours, an interview with the IP was conducted. The IP was informed and acknowledged of the above findings. The IP stated that the clean laundry area should be kept clean for infection control purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 40 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bed Safety revised date 12/2007 showed to try to prevent deaths/ injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, foot board and bed accessories) the facility shall promote the following approaches: - Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the FDA (Note: the review shall consider situations that could caused by the resident's weight, movement or bed position.); and - Identify additional safety measures for resident show have been identified as having higher than usual risk for injury including entrapment (such as altered mental status, restlessness, etc.). According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's document titled Bed Assignment Log Cart 2 dated 6/28/22, showed the bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 41 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 frame, mattress length, and side rails were inspected. Level of Harm - Minimal harm or potential for actual harm Review of the facility's document titled Maintenance Side Rail Risk and Entrapment Assessment form showed the listed questions about the gap between the side rail and headboard; side rail being fitted correctly, secure, compatible with the bed frame and in good working order; access to call bell; electrical cord in working condition; and bed overall in good working order. Residents Affected - Few Review of the facility's document titled Bed Zone Measurements showed Zones 1, 2, 3, 4, 6, and 7 were inspected. The column for Zone 5 showed N/A. The document showed Zone 5 was not inspected for possible entrapment. Further review of the residents' medical records and facility document showed the residents beds in the facility were not properly inspected for possible entrapment. For example: 1. On 3/1/23 at 1250 hours, 3/2/23 at 1153 hours, and 3/3/23 at 0843 hours, Resident 40 was observed in bed with bilateral side rails elevated. Medical record review for Resident 40 was initiated on 2/28/23. Resident 40 was readmitted to the facility on [DATE]. Review of Resident 40's Order Summary Report showed a physician's order dated 2/9/23, for bilateral 1/4 (quarter) side rails in bed as enabler for bed mobility. Review of the Side Rails Screening Tool dated 2/8/23, showed the IDT recommended the use of side rails, and Resident 40 was able to hold on the rails during ADLs such as for bed mobility and for turning . Cross reference to F700, example #1. On 3/3/23 at 1413 hours, an interview with the MT and DON. The MT stated the maintenance department was responsible for the bed inspection, maintenance of the side rail risk, and entrapment assessment. When asked about the bed inspection process, the MT stated he checked if there was a gap between the mattress and the side rails. When asked when the bed inspection and side rail risk and entrapment assessments should take place, the DON stated these should be done upon admission and would be conducted every six months by the maintenance department. The MT stated the bed inspection, maintenance of the side rail risk, and entrapment assessment were done every six months. When asked for the most recent bed inspection, the MT showed the Bed Assignment Log Cart 2 dated 6/28/22. The DON and MT verified the bed inspection and the side rail risk and entrapment assessments were not conducted every six months. When asked for the bed inspection and side rail risk and entrapment assessments conducted for Resident 40, the DON and MT could not provide documentation. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment were present based on the change of the bed, or mattress, or user, the MT answered no. The MT stated he was not informed when a resident switched bed or mattress. The MT stated he did not know he had to inspect the bed for possible entrapment each time there was a change of bed, mattress, or resident. 2. On 2/28/23 at 0841 hours, 3/1/23 at 1015 hours, and 3/3/23 at 0902 hours, Resident 14 was observed in bed with low air loss mattress and bilateral side rails elevated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 42 of 43 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowntree Gardens 12151 Dale Avenue Stanton, CA 90680 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 14 was initiated on 2/28/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed a physician's order dated 1/12/23, to provide bilateral 1/4 side rails up when in bed as an enabler for bed mobility. Residents Affected - Few Further review of Resident 14's Order Summary Report showed a physician order dated 2/15/23, to provide low air loss mattress for maintenance. Review of Resident 40's MDS dated [DATE], showed Resident 14 required extensive assistance with two persons assistance for bed mobility. On 3/3/23 at 1415 hours, an interview and concurrent document review was conducted with the MT and DON. The MT stated the maintenance department was responsible for the bed inspection, maintenance of the side rail risk and entrapment assessment every six months. When asked if the MT conducted the bed inspection and side rails risk and entrapment assessments when there was a change of room, bed, or mattress, the MT stated no. The DON stated the facility had no process for notifying the maintenance department when changes occurred. When asked for the most recent bed inspection, the MT showed the Bed Assignment Log Cart 2 documentation dated 6/28/22. The MT stated the bed inspection and side rail risk and entrapment assessments were not done in December 2022. The MT and DON made aware of Resident 14's admission to the facility on 1/10/23. When asked if the bed inspection and side rails risk and entrapment assessments were conducted for Resident 14, the MT and DON acknowledge they were not done. Cross reference to F700, example #2 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555718 If continuation sheet Page 43 of 43

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Citations

28 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0018GeneralS&S Cno actual harm
Establish procedures for tracking staff and patients during an emergency.
0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0511GeneralS&S Cno actual harm
Have properly installed electrical wiring and gas equipment.
0521GeneralS&S Dpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0867GeneralS&S Dpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0909GeneralS&S Dpotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

FAQ · About this visit

Common questions about this visit

What happened during the March 3, 2023 survey of ROWNTREE GARDENS?

This was a inspection survey of ROWNTREE GARDENS on March 3, 2023. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ROWNTREE GARDENS on March 3, 2023?

Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish procedures for tracking staff and patients during an emergency."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 3, 2023