Health inspection·February 10, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to send the required discharge referral documents to the HHA for one of three sampled residents (Resident 1). This failure resultedin Resident 1 not receiving the ongoing care needs. Findings: Review of the facility's P&P titled Discharge Summary and Plan revised October 2022 showed the post discharge plan is developed by the care planning team with the assistance of the resident and his or her family and includes: a. Where the individual plans to reside b. Arrangements that have been made for follow- up care and services On 1/30/25 at 1421 hours, CDPH, L&C Program received a complaint stating Resident 1 did not receive PT services until the PT order was faxed on 1/29/25. The complaint showed the discharge team had waited 12 days to do anything. On 2/6/25 at 1140 hours, a telephone call was conducted with Resident 1's family member. Resident 1's family member stated Resident 1's home health with PT services was not arranged. Closed medical record review for Resident 1 was initiated on 2/6/25. Resident 1 was admitted to the facility on [DATE], and discharged on 1/17/25. Review of Resident 1's Physician Order dated 1/16/25, showed to discharge Resident 1 on 1/17/25, to Facility A with home health services, including to provide RN services for medication management and PT services for safety. Review of Resident 1's Discharge Summary/Comprehensive assessment dated [DATE], showed Resident 1 needed assistance with bathing, dressing, eating, personal hygiene, bed mobility, toilet use and was dependent on transfers. Review of Resident 1's Post Discharge Plan of Care dated 1/17/25, showed Resident 1 was transferred to Facility A. The section for the Post Discharge Plans/Community Agencies showed for home health services. (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 2 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 02/10/2025 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)