Cycle 1
Health 2025-03-06 · Fire 2025-03-06
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Westminster, CA
Stanley Healthcare Center
2-star overall rating with 3-star inspections with 24 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
14102 Springdale Street, Westminster, CA
(714) 893-0026
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Progressive Health Care Centers
Operator or chain grouping
Approved since
1995-12-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 1 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.12
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.13
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover · state 38% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 16.28% |
8.2%
8.1 pts better
|
Numerator 7 · Denominator 43 |
| Staff flu vaccination coverage | 67.39% |
42%
25.4 pts better
|
Numerator 31 · Denominator 46 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
1.6%
2.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.5% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
4.1%
0.5 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 46.7% |
13.7%
33 pts worse
|
19.6%
27.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.3% |
14.2%
15.1 pts worse
|
16.7%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
10.7%
3.3 pts worse
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.0%
0.5 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
10.9%
7.8 pts worse
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
4.7%
2.9 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 14.3% · Q4 7.9% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
94.0%
2.3 pts worse
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 85.7% · Q3 96.8% · Q4 97.2% · 4Q avg 91.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
93.2%
1.8 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
22 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-05-05 · Fire 2023-05-05
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-19
F · Potential for more than minimal harm
2025-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-19
E · Potential for more than minimal harm
2025-03-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-19
D · Potential for more than minimal harm
2025-03-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-19
D · Potential for more than minimal harm
2025-03-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-19
F · Potential for more than minimal harm
2024-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-17
E · Potential for more than minimal harm
2023-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-05-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-05-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-05-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-05-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-05-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-05-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-23
C · Minimal harm
2023-05-05
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-05-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-25
B · Minimal harm
2025-05-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-05-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-15
B · Minimal harm
2025-05-16
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-06-15
B · Minimal harm
2025-05-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-15
B · Minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-15
E · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F909 · Environmental Deficiencies
Health
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.
Corrected 2025-04-06
B · Minimal harm
2025-03-06
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-06
B · Minimal harm
2025-03-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-06
B · Minimal harm
2025-03-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-04-06
B · Minimal harm
2025-03-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-06
B · Minimal harm
2024-04-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-03-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-07
E · Potential for more than minimal harm
2024-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-04
E · Potential for more than minimal harm
2024-03-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-03-14
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-03-14
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-03-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-14
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-03-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-05
B · Minimal harm
2024-03-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-03-22
B · Minimal harm
2024-03-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-20
B · Minimal harm
2024-03-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-22
G · Actual harm
2023-05-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-05
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-05
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-05
F909 · Environmental Deficiencies
Health
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.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-16
B · Minimal harm
2023-05-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
Ownership
Goings, Verna
5% Or Greater Direct Ownership Interest · Individual
Larson, Maria
5% Or Greater Direct Ownership Interest · Individual
Davis, Michael
W-2 Managing Employee · Individual
Goings, Gregory
Corporate Officer · Individual
Kilian, James
Corporate Officer · Individual
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4-star overall rating with 3-star inspections with $13,923 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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5-star overall rating with 4-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Rowntree Gardens
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4-star overall rating with 3-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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