Rosecrans Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plans were:1. Updated quarterly for three of seven sampled residents (Resident 4, 5, and 25)2. Revised for one of seven sampled residents (Resident 87)These failures had the potential to result in Residents 4, 5, 25, and 87 not receiving the specific and timely care related to their illnesses and diagnoses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date food items in the pantry, refrigerator and freezer, and did not securely store prepared raw fish in flat tray. These deficient practices had the potential to cause food-borne illness for all residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the physician for one of five sampled residents (Resident 2) was notified when Resident 2 had redness and exudate (a fluid that leaks out onto skin surface in response to inflammation, injury, or infection) at the insertion site of the perma-catheter (a long, flexible tube inserted into a large vein and threaded near the heart). This deficient practice had the potential to delay medical evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was accurate for one of five sampled residents (Resident 107). This deficient practice had the potential to result in an inaccurate identification of specialized mental health service needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered language and communication care plan for one of five sampled residents (Resident 45). This deficient practice had the potential to result in Resident 45 having a communication barrier with staff.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the correct low air loss mattress (LALM, a specialized mattress support surface used to prevent and treat pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) setting. This deficient practice had the potential for Resident 2 to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 70) had an identification (ID) band on their wrist or ankle. This failure had the potential to result in Resident 70 not being properly identified for medical care and procedures.

Inspectors wroteBased on interview and record review, the facility failed to provide transportation to a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) clinic for one of five residents (Resident 17). This deficient practice had the potential to result in dangerous buildup of toxins in the body and fluid overload (the body retains too much sodium and water).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services Director (SSD) planned for transportation to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one of five residents (Resident 17). This deficient practice resulted in Resident 17 missing one dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist conducted a monthly Medication Regimen Review (MMR) for one of five sampled residents (Resident 10). This failure had the potential to result in Resident 10 receiving unnecessary medication and could lead to adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the cultural and ethnic needs of food choices were identified for one of five sampled residents (Resident 107). This deficient practice placed Resident 107 at risk for being dissatisfied with meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist attended the February 2026 and May 2026 Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings. This failure resulted in the facility not meeting the minimum required members for the monthly committee meeting.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the perma-catheter (a long, flexible tube inserted into a large vein and threaded near the heart) was maintained in a clean and sanitary manner for one of five sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to develop an infection.

Inspectors wroteBased on interview and record review, the facility failed to notify a residents' responsible party (RP) of a change in condition for one of three sampled residents (Resident 3). This deficient practice had the potential to violate Resident 3's RP's rights to be informed of changes to the plan of care.

Inspectors wroteBased on interview and record review, the facility failed to document behavioral interventions as indicated on the care plan for one of two sampled residents (Resident 1) following an altercation with Resident 2. This failure had the potential to result in continued behavioral escalation and increased risk of physical harm to other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to:1. Ensure one out of three sampled residents (Resident 1) unwitnessed injury to the left eye was reported to California Department of Public Health (CDPH). This deficient practice of not reporting to CDPH within 24 hours of an unwitnessed injury resulted in discoloration (a localized area of altered skin color that indicates underlying tissue damage) to the left eye. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Refrigerators and Freezers which indicated to monitor and record the refrigerator and freezer temperatures daily, for 3 of 3 refrigerators and 2 of 2 freezers. This failure had the potential to cause food spoilage (the deterioration of food due to various factors, resulting in an undesirable change in its appearance, taste, texture, or nutritional value) and lead to foodborne illnesses (any illness caused by consuming foods or beverages contaminated with harmful bacteria, viruses and parasites or their toxins [poisonous substances produced by organisms like bacteria that harm the body]).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of two shower rooms (east shower room), by failing to ensure the shower floor and wall were clean and disinfected from fecal matter (the solid waste passed out of the body of a human through the bowel). This failure had the potential to spread bacteria and germs that could lead to infection for facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy during care for three of eight residents (Residents 2, 3, and 4) when certified Nursing Assistants (CNA) 1, CNA 2, and CNA 3 did not fully close the privacy curtains while providing care. This failure had the potential to affect the dignity and self-worth of Residents 2, 3, and 4.

Inspectors wroteBased on interview and record review, the facility failed to notify one of four sampled residents (Resident 1), at least 30 days prior to the resident's discharge plan on 7/19/2025, as indicated in the facility's policy and procedure (P&P) titled, Transfer and Discharge Notice. This deficient practice resulted in Resident 1 not being aware of the discharge plans and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Residents 2), was not trapped in Resident 1's room on 7/15/2025 at 4:00 a.m. This failure had the potential to cause resident to resident altercation and resident injuries, leading to hospitalization.1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness, abnormalities of gait and mobility (deviations from the typical manner of walking,) and Atrial Fibrillation (irregular heartbeat.)During a review of Resident 1's H&P dated 6/26/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had intact cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for signs and symptoms of bleeding and bruising related to the use of aspirin (a medication used to prevent blood clots) and Eliquis (a medication used to prevent blood clots) between 4/1/25 and 4/24/25 in one of five residents sampled for unnecessary medications (Resident 82). The deficient practice of failing to monitor for signs and symptoms of bleeding during aspirin and Eliquis therapy increased the risk that Resident 82 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to medical complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one opened vial of latanoprost (a medication used to treat eye conditions) eye drops with an open date affecting Resident 16 in one of two inspected medication carts (East Medication Cart). 2. Store lorazepam oral solution (a medication used to treat mental illness) in the refrigerator per the manufacturer's requirements affecting resident 410 in one of two inspected medication carts (East Medication Cart). 3. Store gabapentin oral solution (a medication used to treat nerve pain) in the refrigerator per the manufacturer's requirements affecting resident 410 in one of two inspected medication carts (East Medication Cart). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sample residents (Resident 30) had an intravenous (IV- a thin flexible tube inserted into the vein used to draw blood and give treatments) catheter with the date of insertion on it. This deficient practice had the potential for Resident 30's IV site to go unchanged which could lead to an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 82) had their oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) checked every shift as ordered. This deficient practice had the potential for Resident 82 to be receiving too much or too little oxygen and could lead to difficulty in breathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents in Rooms 6, 7, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29 had at least 80 square feet ([sqft]- a unit of measure) of living space. This deficient practice had the potential to result in residents not being able to move around freely or store personal items. This also had the potential for staff having difficulty providing care due to a lack of space.

Inspectors wroteBased on interview and record review, the facility failed to manage a resident ' s pain (Resident 1) after the resident complained of pain to the licensed nurse. This failure resulted in Resident 1 experiencing unrelieved pain and had the potential to interfere with activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound dressings for two of three sampled residents (Resident 1) were labeled with the nurse's initials, time, and date. This failure had the potential to result in wound dressings not being changed, resulting in wound infections and delayed wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Enhanced Standard Precautions ([ESP] a framework for reducing multi drug-resistant organism [MDRO] transmission by using gowns and gloves while caring for residents at high risk for MDRO transmission, at the point of care during specific activities, by contmainating health care workers' hands, clothes and the environment), which indicated to don (put on) PPE within room, before engaging in activity (resident care), if splash is anticipated, for two of eight sampled residents (Residents 6 and 7), who had physician ' s orders for wound care. This deficient practice had the potential to result in transmission of a disease-causing organisms, affecting the other residents in the facility, and the potential for the affected residents ' delay in wound healing process.

Inspectors wroteBased on observation and interview, the facility failed to ensure clean linens were not placed near the facility's washing machines where dirty and soiled clothing was stored. This deficient practice placed clean linens at risk for bacteria (small single-celled organisms that cause infection) and had the potential for cross contamination and spread of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure staff promoted dignity while assisting one of two residents (Resident 56) during meals by standing over the resident and not maintaining face to face eye contact. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 56.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure resident and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) for one of three sampled residents (Resident 56). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, and interview the facility failed to ensure one of 20 sampled residents (Resident 6) was provided a safe, clean and homelike environment by failing to provide a room that did not have soiled or peeling paint on the bedroom walls. This deficient practice had the potential for Resident 6 to be exposed to dirt, harsh chemicals, infection and accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] assessment and care screening tool) assessment regarding the pneumococcal vaccine (a biological preparation that prevents the most common and severe forms of pneumonia [lung infection]) was conducted for one of five sampled residents (Resident 75). This deficient practice had the potential to result inaccurate care and services for Resident 75 due to inappropriate MDS care screening and tool assessment practices.

Inspectors wroteBased on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability [a term used when a person has certain limitations in cognitive functioning and skills, including communication, social and self-care skills], or related condition) level one (I) screening and refer one of eight sampled residents (Resident 22) who had a new diagnosis of psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality) to the appropriate state-designated authority for a PASRR level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 22 not receiving appropriate treatment recommendations for psychosis.

Inspectors wroteBased on observation, interviews and record review, the facility failed to initiate a care plan for Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) services for one out of four (4) residents' (Resident 74). This deficient practice had the potential to negatively affect the delivery of necessary care and services. During a review of Resident 74's admission record (face sheet), the admission record indicated Resident 74 was initially admitted to the facility on [DATE], with diagnoses that included ataxia (poor muscle control that causes clumsy movements), muscle weakness (decreased strength in the muscles), repeated falls (more than two falls in a six-month period), and cardiomegaly (an enlarged heart). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one out of four Residents (Resident 43) had a revised care plan to implement an order for a back brace (a device designed to limit the motion of the spine) for support. This deficient practice placed Resident 43 at risk, for providing back support, and had the potential to cause immobility, unsteady gait, and increased back pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral hygiene (cleaning the mouth and tongue) for one of 20 sampled residents (Resident 92). This deficient practice resulted in Resident 92 having poor oral hygiene with the presence of thick yellowish particles on the mouth and tongue that could lead to an oral infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three residents (Resident 3) her preferred activity to stay in the dining recreation area to participate in group activity. This deficient practice had the potential to decrease Resident 3's social interaction, sense of belongings, depression, and emotional health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 22), with a limited range of motion, was provided with a left hand roll (a device that prevents fingers from curling up tightly) as ordered by the physician. This deficient practice had the potential to result in further decline in range of motion and worsening of contracture (decrease in passive range of motion at a joint) for Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who received hemodialysis ([HD] process of removing waste products and excess fluid from the body) received treatment in accordance with standards of practice for one of two sampled residents (Resident 75) by failing to: 1. Ensure the HD emergency kit (E-Kit) was always available at bedside for safety measures for HD complications. 2. Communicate to Resident 75's physician regarding the recommendation of dialysis treatment center staff to limit fluid restriction to 32 ounces ([oz] measures volume) per day. These deficient practices had the potential to result in staff inability to manage bleeding from Resident 75's dialysis access site in the event of emergency and risk for fluid overload, swelling, shortness of breath and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two medications were labeled with medication open dates for two of two sampled residents (Resident 13 and 77) and to follow manufacturer's guidelines when foil was opened for budesonide inhalation suspension (medication to help with breathing) for Resident 77. This failure had the potential to result in the loss of medication potency and for residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of four Residents (Resident 43) had a back brace ordered by the physician to alleviant (relieve) back pain. This deficient practice did not provide Resident 43 with a back brace to help alleviate back pain and had the potential to place Resident 43 of having increased back pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 75) was offered the pneumococcal vaccine ([PNA] a vaccine that prevents the most common and severe forms of pneumonia [ infection of the lung]). This deficient practice placed Resident 75 at higher risk of acquiring pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 17 out of 41 (Rooms 7, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26 27, 28, and 29) residents' bedrooms measures at least 80 square feet (sq. ft.) per resident in a multi-resident rooms and 100 sq. ft in a single resident room. room [ROOM NUMBER] measured less than 100 sq. ft. per single resident room. This deficient practice placed residents at risk for insufficient space and could have the potential to lead to inadequate nursing care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from injury, by failing to provide two or more staff supervision when providing care with activities of daily living (eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) as indicated in Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/1/2024. The MDS indicated two or more persons will assist Resident 1 with mobility (rolling from left to right, sit to lying, lying to sitting position and with transfer from bed to chair, chair to bed and with tub/ shower transfer), toileting hygiene, shower, and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Administrative Manual titled, Elder/ Dependent Abuse, which indicated to report any allegations of abuse or that results in serious bodily injury, to the State Survey agency, immediately but not later than two hours, for one of three residents (Resident 1). Resident 1 sustained a baseball size (a regulation baseball is 9 to 9.25 inches in circumference) bruise (discolored skin) on her right upper forearm. Resident 1 sustained right upper arm bone fracture (broken bone). This deficient practice delayed the investigation by the California Department of Public Health (CDPH).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Supervise and monitor residents at risk for wandering and elopement (when a resident leaves the facility without the knowledge of the staff), for one of three sampled residents (Resident 1). 2. Ensure the entrance and exit doors of the facility were monitored to prevent Resident 1 from leaving the facility unattended. This deficient practice had the potential to result in an injury for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 2, Resident 3, and Resident 4) who had long rough edges toenails, received foot care and treatment. This deficient practiced placed Residents 2, 3 and 4 at risk for infection of the toenails, pain, and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control policy and procedure (P&P) by failing to ensure staff properly donned (put on) a facemask (protective covering to help prevent spreading of germs and diseases) while in the facility and in resident care areas. This failure had the potential for the spread of transmissible diseases amongst staff, residents, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure (P/P) titled Enteral (passing through the intestine, either naturally via the mouth and throat, or through an artificial opening) Feedings-Safety Precautions which indicated to elevate the head of a resident's bed (HOB) at least 30° during tube feeding (gastrostomy [GT] when a tube is inserted through the stomach to administer food and medication) for 1 of 4 sampled residents (Resident 2). This deficient practice had the potential to result in aspiration (when a person swallowed something and it entered the lungs instead of the stomach), difficulty breathing and death.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P/P) titled Lab and Diagnostic Test Results-Clinical Protocol, which indicated the physician will order diagnostic and laboratory tests based on each resident's condition and nurses will identify the urgency of communicating with the physician based on the request, the seriousness of an abnormal result or the resident's current condition, for 1 of 4 sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 to bruise and bleed.