Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosewood Health Facility during CMS and state inspections, most recent first.
The facility failed to ensure the IP completed required specialty training in infection prevention and control. During interview and record review, the IP stated she had not completed the training and had been working full-time in the role since late October 2025. The job description required specialty training through accredited continuing education and completion of national training requirements.
Delayed call light response affected two residents, including one cognitively intact resident and another resident with a BIMS score of 14. Both residents reported waiting up to an hour for assistance, with one stating staff turned off the call light and did not return and another reporting a soiled diaper while waiting. Records also showed a grievance, a call light response log entry of 34 minutes and 33 seconds, and resident council complaints that call lights were not answered in a timely manner.
Fingerstick glucose checks were performed for 15 residents receiving insulin without a physician order. The MDSC and AMDSC confirmed there were no specific orders for FSBS monitoring, even though the residents had orders for multiple insulin regimens and sliding-scale coverage. The facility policy required a physician order before obtaining a fingerstick glucose level, and the DON stated an order should be in place for FSBS checks.
Infection control practices were not implemented in the laundry area when clean laundry bins had dirt-like debris and personal laundry transport carts had thick dust-like debris on the bottom frame. The LA stated the items had not yet been cleaned, while the HS and MTs gave inconsistent accounts of who cleaned the carts and whether there was any regular schedule or record of work. The facility also failed to document preventative measures in its infection surveillance process despite an increase in new HAIs, and the IP stated she did not review the surveillance worksheet to implement measures.
Failure to Document and Review Antibiotic Use: The facility did not effectively monitor antibiotic use for four residents. The IP found antibiotic orders for UTI and other infections, but the ICPCS lacked documentation of symptoms, culture results, pathogen identification, and, for one resident, the reason an antibiotic was changed. The facility policy required review of all clinical infections treated with antibiotics and documentation on the antibiotic surveillance tracking form.
Laundry dryer filters were observed with thick lint build up in two of three dryers during an observation in the laundry room. An LA stated she had not gotten to clean the filters, and the HS stated she had last seen the filters cleaned several days earlier and does not clean them herself. The facility P&P required the filter and filter area to be cleaned at the end of each shift and for the burner area to be checked for lint build up.
A resident with hemiplegia and hemiparesis after a CVA required substantial/maximal assistance with toileting, but staff did not return after answering her call light for BM assistance, and she ended up having a BM in her brief. The resident said she was embarrassed because it made her room smell and staff had to clean her. Her care plan, MDS, and bowel documentation showed ongoing bowel incontinence and a need for staff assistance with elimination.
Failure to provide timely toileting assistance for a resident with hemiplegia and hemiparesis. The resident required substantial/maximal assist for toileting, could feel the urge to have a BM, and reported that after calling for help, a staff member said she would return but did not, resulting in the resident having a BM in her brief. The resident’s care plan and MDS documented ongoing bowel incontinence, and the DON stated staff should help residents right away when assistance is needed.
QAPI failed to monitor and evaluate infection prevention and control performance data for two months. During a record review with the Administrator and IP, the Infection Control Rounds spreadsheet for the QAPI mtg contained blank fields for multiple infection control indicators, including handwashing, PPE use, and linen storage. The Administrator could not find the missing data, and the IP stated the data for those months had not been tallied.
A resident with high risk for pressure injuries, total dependence on staff for mobility and hygiene, and repeated refusals to turn or reposition did not have a care plan that addressed these refusals. As a result, the resident developed an unstageable pressure injury and a deep tissue injury, both acquired in-house, due to the facility's failure to update the care plan with appropriate interventions.
A resident with a history of falls and dementia was removed from 1:1 monitoring without an IDT meeting or updated fall risk assessment, leading to an unwitnessed fall and fracture. The facility did not follow its policies for care planning and fall prevention, resulting in inadequate supervision and the resident's injury.
A resident with a history of cellulitis was observed with a significant skin condition, including raised, reddened, scaly skin on her neck and shoulder. Despite the condition and the resident's behavior of scratching, facility staff failed to notify the medical doctor promptly. The LVN, CNA, and TXN did not take appropriate action, and the condition was only identified as potentially serious by the DON. The delay in care resulted in a diagnosis of cellulitis and antibiotic treatment.
The facility failed to follow its Water Management Program when the cooling tower tested positive for Legionella, a bacteria causing lung infections. Despite treatment of the water, staff were not in-serviced on Legionella, and the facility did not fully adhere to its policy of identifying and testing residents for Legionella. This oversight potentially exposed residents, visitors, and staff to the bacteria.
A facility failed to update the care plan for a non-verbal resident with significant mobility issues, resulting in Moisture Associated Skin Damage (MASD). The care plan, last revised in September, did not reflect the need for repositioning every two hours after the resident was diagnosed with MASD in October. This oversight was confirmed by the DON, who acknowledged the necessity for more frequent repositioning to prevent skin breakdown.
A resident with a catheter due to kidney stones experienced pain and discomfort, which was not promptly assessed by the responsible LVN. Despite the resident's complaints, the LVN did not investigate the cause of the discomfort and only administered Tylenol. The Treatment Nurse later replaced the leaking catheter, alleviating the resident's pain. The facility's policy required immediate reporting and assessment of such issues, which was not followed.
The facility failed to follow its medication labeling and storage policy, as medications were found at the bedside of two residents without proper assessments or orders, and expired insulin vials were discovered on two medication carts. These deficiencies were confirmed by LVNs and the ADON.
The facility failed to obtain complete informed consent for psychotherapeutic drugs for two residents. One resident received Temazepam without the necessary signatures from a Resident Representative and a facility representative. Another resident's consent forms for Temazepam and Mirtazapine were incomplete. Staff interviews confirmed the deficiencies, and the facility's policy requires signed consent before treatment.
A resident's pain was not controlled due to the facility's failure to administer physician-ordered Glucosamine-Chondroitin tablets over several days. The medication was unavailable, and the pharmacy was not notified. The DON stated that new admission medications should be available within 4-6 hours, and OTC medications can be purchased locally. The facility lacked a policy for notifying the physician when medication was unavailable.
A resident with severe mobility issues and obesity developed Moisture Associated Skin Damage (MASD) due to the facility's failure to follow its repositioning policy. Despite the need for repositioning every two hours, the resident was only repositioned once per shift, as confirmed by the DON and AMDSC. The facility's policy emphasized the importance of regular repositioning to prevent skin breakdown, but it was not adhered to, resulting in the resident's condition.
A facility failed to monitor a resident for behavior changes and side effects after administering psychotropic medications Mirtazapine and Temazepam. Despite the facility's policy requiring monitoring for efficacy and adverse consequences, the resident received multiple doses without appropriate oversight, potentially impacting their health and safety.
The facility did not follow its policy on resident food preferences for two residents. One resident was served asparagus despite disliking it, and their meal tray lacked a green salad. Another resident's preference for a late dinner was not accommodated, requiring a family member to reheat the meal. Staff interviews confirmed these oversights, which were contrary to the facility's policy on updating and honoring resident dining preferences.
A resident with severe cognitive impairment and physical disabilities was dropped off alone at the wrong address due to a failure in communication and adherence to transportation policies. The resident required maximum assistance and supervision, but the Transportation Supervisor was not informed of these needs, resulting in the resident being left unsupervised.
A facility failed to treat a resident with dignity and respect when a CNA told the resident, 'you don't tell me what to do, I tell you what to do.' The resident, who was cognitively intact and required assistance with daily activities, did not report the incident immediately due to fear. The facility's policy requires residents to be treated with dignity and respect at all times.
A resident requiring assistance with personal care was found with uncleaned and untrimmed fingernails, despite being cognitively intact. The facility's documentation lacked records of nail care, contrary to its policy for daily cleaning and trimming to prevent infections. Interviews with staff confirmed the absence of nail care records, indicating a deficiency in supporting the resident's ADLs.
A resident's bottom dentures were reported missing, but the facility delayed the dental referral beyond the 3-day policy requirement. There was no documentation of actions taken to ensure adequate nutrition while awaiting dental services, despite the resident's inconsistent meal intake.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. During a concurrent interview and record review, the IP stated she had not completed the specialized training and reported that she began working as a full-time IP at the end of October 2025 and did not hold any other role in the facility. Review of the facility's Job Description - Infection Preventionist dated 7/8/20 showed that the position required specialty training in Infection Prevention and Control through accredited continuing education and that the IP must meet current national training requirements or have completed them.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for two residents. One resident, who was cognitively intact with a BIMS score of 15, stated that staff were responding within five minutes, turning off the call light, and saying they would return but never coming back. Another resident, with a BIMS score of 14, stated that staff had been timed and that waits of up to one hour had occurred, including one instance in which the resident remained in a soiled diaper while waiting for assistance. The record review also showed prior concerns about delayed call light response. A grievance form documented that the resident reported waiting about half an hour for the call light to be answered, and the call light response time log showed a reset time of 34 minutes and 33 seconds for one call. Resident council minutes from two meetings recorded complaints that call lights were not answered in a timely manner, including reports that staff turned off the call light, said they would return, and did not come back. The facility policy stated that calls for assistance are to be answered as soon as possible, within 0 to 15 minutes, and urgent requests are to be addressed immediately.
Fingerstick Glucose Checks Performed Without Physician Orders
Penalty
Summary
The facility failed to follow its policy and procedure for obtaining a fingerstick glucose level by performing fingerstick blood sugar checks for 15 sampled residents without a physician's order. During interview and record review, the MDS Coordinator and Assistant MDS Coordinator stated that the 15 residents received insulin, but there was no specific physician order for fingerstick blood sugar checks for any of them. The facility's policy titled, Obtaining a Fingerstick Glucose Level, stated that a physician's order is required before the procedure is performed. Record review showed that each of the 15 residents had physician orders for insulin, including long-acting insulin and sliding-scale insulin, with various hold parameters based on blood sugar levels. The residents reviewed included residents with orders for insulin glargine, insulin lispro, Semglee, Lantus SoloStar, Insulin Degludec, NovoLOG FlexPen, and insulin NPH. MARs for fingerstick blood sugar results dated February 2026 were reviewed for each resident, indicating that fingerstick glucose monitoring was being done despite the absence of a specific order for the procedure. During interview, the DON stated that there should be a physician order for FSBS checks. The Assistant MDS Coordinator later confirmed that there were no physician orders for nurses to perform FSBS for any of the 15 residents receiving insulin. The deficiency was based on the facility conducting fingerstick glucose monitoring on residents without the required physician authorization.
Infection Control Lapses in Laundry Cleaning and Infection Surveillance
Penalty
Summary
The facility failed to implement infection prevention practices in the laundry area when three of three clean laundry bins observed in front of the dryers had dirt-like debris and pieces of material at the bottom. During the observation, the laundry aide stated she had not gotten to clean the bins. The facility also had three of three personal laundry transport carts with thick dust-like debris along the bottom frame. The laundry aide stated she would clean the carts right away. The housekeeping supervisor stated she did not know how often the personal laundry carts were cleaned and that maintenance usually power washed them, but maintenance did not have a record of work done on the carts. Maintenance staff stated they did not do regular work on the carts and only changed wheels or cleaned them if asked or if a work order was issued. Record review showed the Simple Work Order Listing included a request to check all laundry carts and organize resident laundry, but there was no documentation of cleaning the personal laundry transport carts. The facility's Laundry and Bedding, Soiled policy stated linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule, and clean linen is protected from dust and soiling during transport and storage. The facility also failed to follow its Surveillance for Infections policy. Review of the surveillance worksheets for September 2025 and October 2025 showed 10 new HAIs in September and 15 new HAIs in October, with no documentation of preventative measures to slow or stop the spread of infection. The infection preventionist stated she did not review the surveillance worksheet to implement preventative measures and that there was no documentation of what measures were implemented.
Failure to Document and Review Antibiotic Use
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program for four sampled residents. During interview and record review, the Infection Preventionist reviewed the Infection Control Prevention & Control Surveillance log and found that Resident 26 had Macrobid ordered for UTI, but there was no documentation of signs or symptoms and no organism identified on culture in the surveillance record. The Infection Preventionist stated the urinalysis did not meet UTI criteria and was not logged in the ICPCS, and also stated she had not checked whether the urine was cultured. Resident 4 had Cefuroxime Axetil ordered for UTI, but the ICPCS did not contain documentation of signs or symptoms or an organism on culture. Resident 3 had orders for Vancomycin HCL, Daptomycin, and Ertapenem sodium, and the Infection Preventionist stated there were no documented signs or symptoms and no organism on culture; she also stated Resident 3 had no symptoms but this was not logged in the ICPCS. Resident 24 had Cephalexin followed by Amoxicillin for UTI, and the Infection Preventionist stated there was no documentation in the ICPCS explaining why the antibiotic was changed. The facility policy required all clinical infections treated with antibiotics to be reviewed and all antibiotic regimens to be documented on the antibiotic surveillance tracking form, including date symptoms appeared, pathogen identified, date of culture, outcomes, and adverse events.
Laundry Dryer Filters Not Cleaned
Penalty
Summary
The facility failed to ensure that two of three laundry dryer filters were free of thick lint build up. During a concurrent observation and interview in the laundry room on 2/10/26 at 8:38 a.m. with Laundry Aide 1, two dryers that were not in use were observed with thick lint build up in each dryer's filters. Laundry Aide 1 stated she had not gotten to clean it. During an interview on 2/12/26 at 11:23 a.m. with the Housekeeping Supervisor, the supervisor stated that Monday, three days earlier, was the last time she saw the filters being cleaned around 8:45 a.m. and 9 a.m., and that she does not go in there and clean the filter. Review of the facility's policy and procedure titled, Cleaning Washers and Dryers, dated 11/14/23, indicated that at the end of each shift, the filter and filter area are to be cleaned, the burner area is to be checked for lint build up, and all easily accessible areas are to be wiped.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided to a dependent resident who required substantial to maximal assistance with toileting due to hemiplegia and hemiparesis following a cerebral infarction affecting her left non-dominant side. During observation and interview, the resident stated she could not use her left side, could still feel the sensation of needing a BM, and needed staff help to get into the bathroom. She reported that when she pressed her call light for help to toilet, a staff member responded, said she would be right back, and never returned, resulting in the resident having a BM in her brief. The resident stated she was embarrassed because the BM in her brief made her room smell and staff then had to clean her. Her care plan identified a deficit in ADL self-care performance related to hemiplegia and hemiparesis and directed that she required substantial/maximal assistance by one staff member for toileting. Her MDS indicated occasional bowel incontinence, and bowel elimination documentation showed multiple incontinent episodes across several months. The DON stated that when residents need assistance, staff should help right away, and the facility policy stated residents are to receive appropriate support and assistance with elimination and that staff must have training on resident rights, including dignity and respect.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided to a dependent resident who required substantial to maximal assistance for toileting. Resident 53 had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. During observation and interview, the resident stated she could feel the need to have a bowel movement but needed staff help to get to the bathroom. She reported that when she pressed the call light for assistance, a staff member responded, said she would be right back, and did not return, and the resident then had a bowel movement in her brief. The resident’s care plan identified an ADL self-care performance deficit related to hemiplegia and hemiparesis and directed that she required substantial/maximal assistance by one staff member for toileting. Her MDS indicated occasional bowel incontinence, and bowel elimination documentation showed multiple episodes of incontinence across several months. The DON stated that when residents need assistance, staff should help right away. The facility policy stated residents are to be provided care and services to ensure ADLs do not diminish unless unavoidable, including assistance with elimination/toileting.
QAPI Failed to Review Infection Control Performance Data
Penalty
Summary
The facility's QAPI committee failed to monitor and evaluate infection prevention and control performance data for August and September 2025. During a concurrent interview and record review on 2/12/26 at 11:00 a.m. with the Administrator, the facility's QAPI records were reviewed. The Administrator stated the QAPI committee met quarterly in 2025 on 1/31/25, 4/23/25, 7/30/25, and 10/17/25, and that each meeting reviewed quality indicator data going back three months. The 10/17/25 meeting reviewed quality indicator data from August, September, and October 2025. The records from the 10/17/25 meeting included the Infection Control Rounds spreadsheet for August, September, and October 2025, which contained ten infection prevention and control quality indicators such as staff handwashing compliance, use of PPE, linen storage, and other infection control indicators. The spreadsheet had no data entered for the infection prevention and control performance indicators for August and September 2025; all fields were blank. The Administrator reviewed the QAPI records and did not find the missing infection prevention and control performance data, and the IP stated that the infection prevention and control performance data for August and September 2025 had not been tallied.
Failure to Develop and Implement Comprehensive Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically regarding the prevention of pressure injuries for a resident identified as high risk. Upon admission, the resident had multiple diagnoses, including a wedge compression fracture and end-stage renal disease, and was assessed as cognitively intact but totally dependent on staff for mobility and hygiene. The resident was determined to be at high risk for pressure injuries based on a Braden Scale score of 11 and had no pressure injuries upon admission. Despite the resident's high risk status and total dependence on staff for repositioning and hygiene, documentation revealed repeated refusals by the resident to turn, reposition, and participate in hygiene care over an extended period. Staff documented these refusals and provided education on the risks and benefits of compliance, but the care plan was not updated to address the resident's ongoing refusals or to outline specific interventions for managing these refusals. The facility's policy required care plans to include measurable objectives and interventions, including those related to resident refusals, but this was not done in this case. As a result of the lack of a comprehensive care plan addressing the resident's refusals and high risk for pressure injuries, the resident developed an unstageable pressure injury to the coccyx and a deep tissue injury to the right heel, both acquired in-house. Interviews with staff and review of documentation confirmed that the care plan did not reflect the resident's pattern of refusal or provide guidance for staff on how to address these refusals, contributing to the development of the pressure injuries.
Failure to Conduct IDT Meeting and Fall Risk Assessment
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) met to discuss the discontinuation of one-on-one (1:1) monitoring for a resident who was at high risk for falls. The resident, who had a history of falls and a diagnosis of dementia, was initially placed on 1:1 monitoring due to staff being overwhelmed with her attempts to get up without assistance. However, the monitoring was discontinued without conducting an IDT meeting to assess the resident's safety, and no fall risk assessment or updated care plan was completed following the discontinuation. The resident experienced an unwitnessed fall at the nurse's station, resulting in a fracture that required surgical intervention. Interviews with staff revealed that the resident was known to be confused and frequently attempted to get out of her wheelchair or bed without assistance. Despite this, the staff did not provide adequate supervision, and the resident was left unsupervised at the time of the fall. The facility's policies and procedures required the IDT to develop resident care plans and conduct fall risk assessments to establish a resident-centered falls prevention plan. However, these procedures were not followed, as evidenced by the lack of an IDT meeting, fall risk evaluation, and updated care plan after the discontinuation of 1:1 monitoring. This oversight contributed to the resident's fall and subsequent injury.
Failure to Address Resident's Skin Condition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding changes in a resident's condition, specifically for one resident who exhibited a significant skin condition. The resident was observed with a large area of raised, reddened, scaly skin on the left side of her neck extending toward her shoulder. Despite the visible condition and the resident's behavior of scratching and picking at the affected area, the facility staff did not promptly notify the resident's medical doctor or take appropriate action to address the condition. Interviews with the facility staff, including an LVN, CNA, and TXN, revealed a lack of awareness and appropriate response to the resident's condition. The LVN assigned to the resident was unaware of the cause of the skin condition and only applied barrier cream as treatment. The CNA noted the resident's constant scratching and itchiness but could not recall how long the condition had persisted. The TXN attributed the condition to the resident's behavior and did not seek further medical evaluation, such as a dermatologist consultation. The Director of Nursing later identified the condition as potentially being psoriasis or eczema, which required medical attention. However, the facility's delay in notifying the resident's medical doctor and obtaining appropriate treatment resulted in a failure to follow their policy on change of condition. This oversight had the potential for negative medical outcomes, as the resident was eventually diagnosed with cellulitis and prescribed antibiotics after the medical doctor was informed.
Legionella Contamination in Cooling Tower
Penalty
Summary
The facility failed to adhere to its Water Management Program policy and procedure when the cooling tower tested positive for Legionella bacteria, which can cause lung infections. The Safety Officer (SO) reported that the cooler connected to the water tower tested positive for Legionella, and the water treatment company treated the water. However, the Director of Nursing (DON) confirmed that staff had not been in-serviced on Legionella or legionella pneumonia. The Infection Preventionist (IP) reviewed the Legionnaire Testing report, which indicated a small amount of Legionella in the cooling tower, but not in the kitchen or health center. Despite this, an internal email suggested the building was not affected. The facility's policy, dated July 2017, required reviewing medical and microbiology records, identifying new and recent residents with healthcare-associated pneumonia, and testing them for Legionella. The Centers for Disease Control and Prevention guidelines emphasize the importance of identifying and investigating Legionnaires' disease cases, especially when positive environmental tests for Legionella occur. The facility's failure to follow these guidelines and its own policy potentially exposed residents, visitors, and staff to the bacteria, as the cooling tower's Legionella levels were above normal, although the sink levels were within an acceptable range.
Failure to Update Care Plan Leads to Skin Damage
Penalty
Summary
The facility failed to update the care plan for Resident 20, who was non-verbal and had diagnoses including weakness or inability to move on the left side of her body, severe loss of strength on the left side, inability to talk, and obesity. The care plan, last revised on 9/27/24, indicated that two staff members were to reposition the resident at least once a shift and as necessary. However, after Resident 20 was diagnosed with Moisture Associated Skin Damage (MASD) on 10/24/24, the care plan was not updated to reflect the need for repositioning every two hours, as stated by the Director of Nursing (DON). This oversight resulted in the development of MASD due to prolonged exposure to moisture, as observed during a staff repositioning on 11/4/24.
Failure to Provide Timely Catheter Care Assessment
Penalty
Summary
The facility failed to adhere to its policy and procedure for catheter care, resulting in a deficiency related to Resident 49. The resident, who had a catheter due to kidney stones and sediment in his urine, reported experiencing pain from the catheter. Despite informing his nurse about the discomfort, no timely nursing assessment or intervention was provided. The Licensed Vocational Nurse (LVN) responsible for Resident 49 acknowledged the complaint but did not assess the cause of the discomfort, instead opting to medicate the resident with Tylenol. The LVN intended to inform the Treatment Nurse (TN) but did not perform the necessary assessment herself. The Treatment Nurse later assessed the situation and found the catheter leaking, subsequently replacing it and relieving the resident's discomfort. The Director of Nursing confirmed that the LVN should have conducted a focused assessment to determine the cause of the catheter discomfort. A review of the facility's policy indicated that any unusual findings, such as pain or signs of complications, should be reported immediately to a physician or supervisor. The failure to follow these procedures led to Resident 49 experiencing unnecessary discomfort.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication labeling and storage, as observed in two instances involving residents and medication carts. Medications were found at the bedside of two residents without a self-medication assessment or physician order, which is against the facility's policy. Specifically, Resident 219 had Calazinc on the bedside table, and Resident 58 had Vitamin A&D ointment at the bedside. Both residents lacked the necessary physician orders and self-medication assessments to keep medications at their bedside, as confirmed by the Assisted Director of Nursing (ADON). Additionally, the facility failed to properly manage the expiration of insulin vials on two medication carts. Four insulin vials were found to be expired, which contradicts the facility's policy that requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. The expired insulins included Insulin Lispro and Insulin Humalog on the South-wing cart, and Insulin Lantus and Insulin Lispro on the West-wing cart. Licensed Vocational Nurses (LVNs) confirmed the expiration of these medications during observations and interviews.
Incomplete Informed Consent for Psychotherapeutic Drugs
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding obtaining informed consent for the use of psychotherapeutic drugs for two residents, Resident 48 and Resident 217. For Resident 48, the Physician Orders indicated the administration of Temazepam through a feeding tube, but the informed consent documentation was incomplete. Specifically, the consent form lacked the signature of the Resident Representative and a facility representative, which is required before initiating treatment with psychotherapeutic drugs. Similarly, for Resident 217, the Order Review History Report showed the administration of Temazepam and Mirtazapine, but the informed consent forms were incomplete. During interviews, both LVN 3 and RN 1 acknowledged the deficiencies in the informed consent process, with LVN 3 indicating that the doctor was responsible for obtaining consent and the nurse for witnessing the signature. The facility's policy clearly states that consent must be signed and documented in the individual's medical record before treatment, which was not followed in these cases.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-ordered medication was available for a resident, resulting in the resident's pain not being adequately controlled. The resident, identified as Resident 217, had a physician order for Glucosamine-Chondroitin tablets to be administered twice daily to manage joint pain. However, the medication was not administered on multiple occasions from November 2nd to November 6th, as documented in the Medication Administration Record (MAR). Licensed Vocational Nurse (LVN) 1 confirmed that the medication was unavailable and stated that the pharmacy should have been notified when medication was not available. The Director of Nursing (DON) indicated that the expectation for new admission medication availability is within 4-6 hours, and over-the-counter medications can be purchased from a local pharmacy if necessary. Despite this, the facility did not have a policy for notifying the physician when medication was unavailable, and no such policy was provided upon request. The resident reported experiencing pain levels of 6 to 7 out of 10 in the left knee, indicating moderate to severe pain due to the lack of medication administration.
Failure to Reposition Resident Leads to Skin Damage
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding repositioning for a resident, resulting in the development of Moisture Associated Skin Damage (MASD). Resident 20, who was non-verbal and had diagnoses including weakness and severe loss of strength on the left side of her body, inability to talk, and obesity, was not repositioned according to the facility's guidelines. The care plan for Resident 20, which should have been updated to reflect a repositioning schedule of every two hours following a diagnosis of MASD, was not revised appropriately. Observations and documentation revealed that Resident 20 was repositioned only once per shift, contrary to the facility's policy. The Director of Nursing (DON) and Assistant Minimum Data Set Coordinator (AMDSC) confirmed the lack of documentation for repositioning during the night shift, indicating a failure to follow the established repositioning schedule. The facility's policy, dated 2001, emphasized the importance of repositioning to prevent skin breakdown and promote circulation, particularly for residents who are immobile or dependent on staff for repositioning. Despite these guidelines, the facility did not ensure that Resident 20 was repositioned every two hours, leading to the development of MASD.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding psychotropic medication use for a resident, identified as Resident 217. The facility did not monitor changes in behavior or side effects for the medications Mirtazapine, prescribed for depression, and Temazepam, prescribed for sleep issues. This oversight was identified during an interview and record review with the Assistant Director of Nursing (ADON), where it was revealed that the facility had not been monitoring the resident for behavior changes or side effects after administering these medications. The facility's policy, dated 2001, requires that psychotropic medications, including anti-depressants and hypnotics, be subject to specific prescribing, monitoring, and review requirements. This includes adequate monitoring for efficacy and adverse consequences. Despite this policy, the facility administered four doses of Mirtazapine and four doses of Temazepam to Resident 217 without the necessary monitoring, potentially affecting the resident's health and safety.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding resident food and dining preferences for two residents. For one resident, the facility did not offer an alternative food item despite the resident's documented dislike for asparagus. Additionally, the resident's meal tray was missing a green salad, which was part of the standing orders. This oversight was confirmed during interviews and record reviews with facility staff, including a CNA and an LVN, who acknowledged the discrepancies in the meal provided to the resident. Another resident's preference for a late dinner was not honored, as reported by a family member who stated that they had to keep the meal tray warm or reheat it later in the evening. Interviews with facility staff, including a CNA and the Certified Dietary Manager, indicated that accommodations for late dining preferences were possible, yet not implemented in this case. The facility's policy on resident food and dining preferences, which emphasizes updating preferences regularly and accommodating individual choices, was not followed, leading to these deficiencies.
Failure to Provide Safe Transportation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide safe transportation for a resident with severe cognitive impairment and physical disabilities, resulting in the resident being dropped off alone at the wrong address. The resident, who had a BIMS score indicating severe cognitive impairment, required maximum assistance for mobility and had significant medical conditions, including hemiplegia, memory deficit, and dysphagia. Despite these needs, the Transportation Supervisor dropped the resident off at an incorrect location without ensuring a family member was present to meet him. The Transportation Supervisor admitted to the mistake and stated that she was not informed by the facility about the resident's need for supervision during transportation. The Social Services Director and Administrator both acknowledged that the resident should not have been left alone due to his cognitive and physical limitations. The facility's policy on transportation required that any special considerations be documented in the resident's clinical record, but this was not effectively communicated or adhered to, leading to the incident.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA). During an interview, the facility's Administrator reported that the resident had informed them that the CNA had stated, 'you don't tell me what to do, I tell you what to do.' The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, did not report the incident immediately due to fear of physical and mental repercussions. The resident required maximum assistance for bathing and lower body dressing and moderate assistance for upper body dressing. The Social Services Director confirmed that the resident was alert, oriented, and capable of making her own decisions. The facility's policy on dignity, dated February 2021, mandates that residents are treated with dignity and respect at all times.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) care for a resident, specifically in maintaining personal hygiene through nail care. The resident, who was cognitively intact and required assistance with personal care, was observed with long fingernails containing dark gray debris. The resident reported that her fingernails had not been cleaned or trimmed for several days, indicating a lack of necessary support from the facility staff. The facility's documentation, including the CNA Weekly Skin Report and the ADL flowsheet, showed inconsistencies and omissions in recording nail care for the resident. Despite the facility's policy requiring daily cleaning and regular trimming of nails to prevent infections, there was no documentation of such care being provided. Interviews with staff, including a CNA and the Director of Nursing, confirmed the absence of nail care records, highlighting a deficiency in adhering to the facility's established procedures for supporting residents' ADLs.
Failure to Provide Timely Dental Services and Nutritional Support
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding dental services for a resident who lost their bottom dentures. The resident's family reported the missing dentures on May 23, 2024, but the facility did not coordinate a dental evaluation for replacement until June 6, 2024. This delay in referral was contrary to the facility's policy, which required a referral within three days of the dentures being lost. Furthermore, there was no documentation of any measures taken to ensure the resident could eat and drink adequately while awaiting dental services. The resident's meal intake logs from May 2024 showed inconsistent and often inadequate food consumption, with instances of 0% intake during meals. Despite these observations, the facility did not document any interventions to address the resident's nutritional needs during the period they were without dentures. The lack of timely referral and absence of documented nutritional support measures contributed to the deficiency identified by the surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 228 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bakersfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Julian Healthcare Center | 2.6 mi | ★★★★★ | 25 | 0 |
| Valley Healthcare Center | 2.7 mi | ★★★★★ | 26 | 0 |
| The Orchards Post-acute | 4 mi | ★★★★★ | 2 | 0 |
| Kern River Transitional Care | 4.2 mi | ★★★★★ | 2 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 4.4 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.