Rosewood Post Acute

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three residents (Resident 1) maintained an acceptable weight. This failure resulted in Resident 1 having a 20.6 % weight loss. During a review of Resident 1's admission Record (AR), dated 5/8/26, the AR indicated Resident 1 was admitted from an acute care hospital where Resident 1 was treated after sustaining several fractured bones. During a review of Resident 1's Multi Data Set (MDS- an assessment tool used to plan a resident's care) Section C - Cognitive Patterns, dated 4/30/26, MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - an assessment which measures thinking ability) received a score of 6 out of a possible 15, which indicated impaired thinking ability. During an interview on 5/5/26 at 9:15 a.m. with Resident 1, Resident 1 stated, Resident 1 often did not feel like eating. [...]

Inspectors wroteCross Reference F689Based on interviews and record reviews, the facility failed to report Resident 1's elopement to the California Department of Public Health (CDPH). During the incident, the resident suffered a left knee laceration but was unable to explain how it occurred. This failure had the potential to put the resident's safety at risk and delay the investigation of CDPH. On 5/28/26 at 12:10 p.m., an unannounced visit was conducted at the facility to investigate a complaint. During a review of Resident 1's Departmental Notes indicated that the resident was discovered missing on 5/25/26 at approximately 5:00 a.m. and was later located at the 7-Eleven store across the street from the nursing home at 5:30 a.m. During an interview on 5/28/26 at 1:44 p.m. [...]

Inspectors wroteCross Reference F609Based on interview and record review, the facility failed to provide adequate supervision when Resident 1 eloped from the facility. This failure had the potential to put the resident's safety at risk. A review of Resident 1's Departmental Notes indicated that the resident was discovered missing on 5/25/26 at approximately 5:00 a.m. and was later located at the 7-Eleven store across the street from the nursing home at 5:30 a.m. During an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 5/25/26 at 5:00 a.m., Resident 1 was missing from the facility. CNA 1 stated the resident was last seen lying in bed in his room at approximately 4:30 a.m. CNA 1 further stated that at 5:30 a.m., she found the resident inside the 7-Eleven store across the street from the facility sitting in a wheelchair and Resident 1 told CNA 1 he wanted to go home. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (an assessment of the resources and staffing that the facility needs to competently care for the specific patient population) was complete when the following required components were not included. 1. Staffing plan 2. Staff training/education and competencies This failure had the potential to negatively affect a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cold drinks were held at 41 degrees Fahrenheit or below during lunch tray line. This failure had the potential to result in the growth of bacteria, placing the residents at risk for contracting a food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents received ordered Restorative Nursing Assistant services (RNA-services to help regain and maintain functional abilities through rehabilitative care) when:1. Resident 65 did not receive passive range of motion (PROM-movement of a joint through its full range by external force) or RNA services three days a week, as ordered by the physician, for approximately 8 months.2. Resident 30 did not receive RNA services as ordered by the physician. These failures had the potential to result in a decrease in mobility, decrease in muscle tone, and functional decline for Resident 65 and Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (a representative who may exercise the resident's rights) (RP) for one of three sampled residents (Resident 1) had sufficient notice of the care planning conference. This failure resulted in RP not being able to attend the care planning conference, not being informed of proposed treatment and not being included in making treatment decisions regarding Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (a representative who may exercise the resident's rights) (RP) for one of three sampled residents (Resident 1) had sufficient notice of the care planning conference. This failure resulted in RP not being able to attend the care planning conference and not being involved in planning Resident 1's care.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 on the left side of his face. This failure resulted in Resident 1 having pain, swelling and redness near the left eye. During a record review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE]. The record indicated Resident 1 had diagnoses which included dementia (a loss of brain function affecting memory, thinking, language, judgment, or behavior). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 1/14/26, the record indicated Resident 1 was rarely/ never understood, had a memory problem, and never/rarely made decisions regarding tasks of daily life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for one out three sampled residents (Resident 1), there was no personal belongings inventory form filled out. Resident 1's personal inventory form was not filled out during admission. This failure resulted in an inaccurate inventory f resident's personal belongings.

Inspectors wroteDuring an interview on 7/31/25 at 9:31 a.m., with Resident 1's family member (RFM) 1, RFM 1 stated Resident 1 told her that LVN 1 hit Resident 1 in his right leg when LVN 1 told the resident to scoot back to his bed. RFM 1 stated she spoke to LVN 1 about the incident and LVN 1 denied the allegation. RFM 1 stated she could not remember the date of the incident. Review of Resident 1's departmental notes did not indicate an incident when resident accused LVN 1 of hitting his right leg. During a review of Resident 1's admission Record, dated 7/31/25, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Responsible Party (RP is the person designated as being responsible for another person's medical and financial decisions) of Resident 1 ' s change of condition (COC). This failure resulted in Resident 1 ' s RP being uninformed and unaware of Resident 1 ' s COC.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care to maintain good grooming and personal hygiene to four of six sampled residents (Residents 56, 90, 97, 59) who were dependent on staff to carry out activities of daily living (ADL). This failure resulted to Residents 56, 90, 97 and 59 having long and dirty fingernails.

Inspectors wroteBased on interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for two of 20 sampled residents (Resident 13, Resident 97) when the physician order for PROM (Passive Range of Motion) exercises for Resident 97 was not implemented and Resident 13 had no physician order for ROM (Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine). This deficient practice had the potential to result in the residents' increased and worsening of a contracture (contracture is the shortening and hardening of muscles and joints which limit and interfere with daily functioning)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions when: 1. Dry food items were stored less than six inches from the floor. 2. [NAME] (CK) 1 did not wear a beard restraint while preparing resident food. 3. Expired yogurt was stored in the resident refrigerator. 4. Two ice scoops were stored uncovered and open to air. These failures had the potential for contamination of food resulting in food borne illness for the 63 residents who received food from the kitchen, 25 residents who received ice from unit three and two residents who received ice for unit one. During an observation on 2/24/25, at 9:47 a.m., in the dry food storage area, one bulk container of powdered milk, one bulk container of sugar and one bulk container of flour were stored approximately 4.5 inches above the floor. [...]

Inspectors wrote3. During an observation on 2/26/25 at 9:26 a.m., in the shared bathroom for rooms [ROOM NUMBERS], the toilet bowl was dirty with red substance that appeared like blood around the toilet seat and outside the right side of the toilet bowl. On the floor near the toilet, were three areas of dry dark red substances. Also on the floor was a dry brown substance that looked like feces. There was a trash bin that had no liner near the toilet. During a concurrent observation and interview on 2/26/25 at 9:28 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 acknowledged that the bathroom (B/R) was dirty, needed to be cleaned for sure, and needed good cleaning. CNA 4 stated housekeeping comes in everyday to clean, usually by 11 a.m. or 10:30 a.m. CNA 4 stated she has not seen it this morning as the resident involved was assisted by the night staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when: 1. The toilet seat/cover was loose and was the wrong size for the toilet in rooms [ROOM NUMBERS]'s (shared bathroom). There was a gap between the toilet bowl and the toilet seat when closed. 2. The linoleum flooring in rooms [ROOM NUMBERS]'s bathroom was discolored with patches of black stains. This failure placed Resident 155 at risk for safety and may negatively impact the resident's psychological health when she has to use an unmaintained bathroom that is not safe and clean.

Inspectors wroteBased on observation interview and record review, the facility failed to assure medications were stored in a secure location when two opened and uncapped Clotrimazole cream tubes were found on Resident 18's bedside table (Clotrimazole cream is a medicated cream used to treat skin infections). This deficient practice had the potential for medication misuse and/or ineffective treatment. (Cross Reference F880)

Inspectors wroteBased on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents for 34 of 34 rooms ( Rooms 103, 105, 108, 109, 110, 111, 112, 114, 115,116, 118, 123, 124, 200, 201, 202, 203, 204, 206, 208, 210,212,215,319,321,323,324,325,326,327,329,330,331 and 332). The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings.

Inspectors wroteBased on interview and record review, for two of three sampled residents (Resident 2 and Resident 3), the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan when: 1. For Resident 2, physician's orders to monitor Foley (a type of an indwelling urinary catheter, a flexible tube that is passed into the bladder to drain urine) catheter urine output was not followed and change in urine character/characteristics was not reported to the physician as ordered. This failure resulted in Resident 2's transfer to the hospital that required intravenous (administration of fluids into the person's veins) antibiotics to treat a urinary tract infection. 2. [...]

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to provide assistive device and adequate supervision to prevent accidents when a two-person assist during Activities of Daily Living (ADLs, activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) for bed mobility (moving from one bed position to another like rolling from side to side in bed) care was not provided. This failure resulted in Resident 1 falling out of bed and sustaining a nasal bone fracture and facial bruising.

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 1), the facility failed to ensure Resident 1 was free from verbal abuse when Certified Nursing Assistant (CNA) 1 yelled at Resident 1 Why don't you shut the hell up! during a verbal altercation. This failure had the potential to result in further conflict and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse when facility did not conduct reference check on Certified Nursing Assistant (CNA) 1 prior to hiring. This failure had the potential to result in exposing residents to staff that may have propensity for abusive behavior.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dietary staff stored and prepared food under sanitary conditions for 89 of 97 residents whose food were prepared in the kitchen. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications below a five percent (5%) error rate when: 1. A Licensed Vocational Nurse (LVN 1) did not administer sertraline (a drug used to treat depression; a mental health disorder associated with low mood) 100mg and lidocaine patch (a patch used for temporary pain relief) 4% to one (Resident 31) of 19 sampled residents. 2. A second Licensed Vocational Nurse (LVN 2) did not administer chlorhexidine mouthwash (a prescribed mouthwash that decreases bacteria in the mouth) to one (Resident 83) out of 19 sampled residents. These errors have resulted in Resident 31 and 83, not receiving medication as prescribed by their physicians.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that biologicals were labeled and stored according to professional standards when 1. Aluminum packages of 55 vials of ipratropium-albuterol inhalation solution were left open to air and light 2. A vial of timolol maleate ophthalmic solution was unlabeled and undated. This failure had the potential to result in administering ineffective medications to residents which could lead to residents health care needs being unmet and potential hospitalization. Findings 1 . During a concurrent medication storage observation and interview on 9/27/23 at 11:15 a.m., with Registered Nurse (RN 1), four aluminum packages were observed unrolled and left open and without open dates at Station 1's Medication Cart 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide an accurate Minimum Data Assessment (MDS- an assessment used to guide plan of care) for one of 20 sampled residents (Resident 392) for Resident 392's Hospice (the provision of care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) care status. This deficient practice resulted in reflecting inaccurate care status for Resident 392 and had the potential for Resident 392 to receive care that was not appropriate to his medical, functional and/or psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide no less than 80 square feet per resident for 18 of 51 rooms (Rooms 103, 105, 109, 111, 112, 114, 115, 118, 123, 124, 200, 201, 202, 203, 204, 206, 208, and 210). This failed practice had the potential to result in lack of sufficient space for staff to deliver care and provide storage space for resident belongings.