Rowntree Gardens

In the surveyor’s words

From the most serious findings on record at Rowntree Gardens, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Dec 11, 2025

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 7 and 36) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure the monitoring for Resident 7's behavior for the use of the divalproex (anticonvulsant medication used to manage bipolar disorder) and escitalopram (antidepressant) medications were specific. * The facility failed to ensure the monitoring for Resident 36's behavior for the use of aripiprazole (antipsychotic medication) was specific and consistent to the resident's diagnosis. […]

• No harm, potential for more than minimal, patternF688Dec 11, 2025

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided as per the physician's order to prevent a decline in ROM (range of motion) functions for one of two final sampled residents (Resident 41) reviewed for range of motion. * The facility failed to follow a physician's order to apply the PRAFO boot (a specialized medical brace that stabilizes the ankle and foot, primarily to prevent and treat heel skin breakdown (ulcers) by keeping the heel elevated and offloaded, while also managing conditions like foot drop, contractures, and neurological deficits) to Resident 41's left foot when in bed. […]

• No harm, potential for more than minimal, patternF726Dec 11, 2025

  Based on interview, facility P&P review, and facility document review, the facility failed to ensure the licensed nurses had specific competencies and skill sets needed to care for the residents. * The facility failed to conduct the staff competency check for the use of PureWick external catheter (a non-invasive device for managing urinary incontinence). This failure placed the residents at risk for unsafe practices and adverse outcomes. Findings: Review of the facility's P&P titled Staffing, Sufficient and Competent Nursing dated 10/24/24, showed Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. […]

• No harm, potential for more than minimal, patternF741Dec 11, 2025

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the NPI (nonpharmacological intervention) was implemented for three of five final sampled residents (Residents 7, 10, and 36) reviewed for unnecessary medications. * The facility failed to ensure the licensed nurses implemented the NPI and documented its effectiveness for Resident 7's observed behaviors related to the use of the divalproex (anticonvulsant medication) and escitalopram (antidepressant) medications. * The facility failed to show documentation for NPI for Resident 10's use of the Depakote (medication for mood stabilizer), quetiapine (medication to control aggressive behavior), bupropion (antidepressant medication), and buspirone (antianxiety medication). […]

• No harm, potential for more than minimal, patternF812Dec 11, 2025

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the kitchen equipment were kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure the food was past the use-by date were discarded. * The facility failed to ensure the food brought from outside was properly labeled and stored as per the facility's P&P. * The facility failed to ensure a food preparation sink had an air gap for back flow prevention. […]