Rosewood Retirement Community

Maintain records of centrally stored medication dosages

Based on observation, interviews, and record review, the licensee did not comply with the section cited above in that the centrally stored log for R1 and R2 did not have a start date for some medications,which poses/posed a potential health, safety or personal rights risk to persons in care.

First aid training requirements

Based on observation and record review, the licensee did not comply with the section cited above in that LPAs observed eight out of 20 staff files reviewed had expired CPR/First Aid, which poses/posed a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Documentation and interviews revealed following incidents were not reported to CCLD: On 11/07/2025, resident trapped; elevators down due to outage, on 11/11/25, the elevator was stuck between the third and fourth floor, and on 11/25/25, three residents were stuck in the elevator.

Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. R4 and R5 are on Oxygen as ordered by their Physician. Both Physician's Reports indicate that they cannot administer own Oxygen.

Resident access to hazardous items with safety review

Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Medications were found in the rooms of R5 and R6. Chemicals/cleaning supplies found in rooms R4, housekeeping cart in memory care was unattended in hallway with accessible disinfecting cleaner, memory care bathroom cabinet was not locked but stored disinfecting cleaner.

Assist residents with self-administered medication

Based on observation and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. R5 - Senna start date 3/20/25 1 tab QD. 30 day supply, there should be 24 pills but there are 26 pills remaining. 2 pills not given as ordered. R6 - Lasix - Start date 2/19/25 order states 1 pill every 2 days. From 2/19/25-3/25/25 - 18 pills should have been given. There should be 72 pills remaining but there are 71. 1 pill ws not given as ordered.

Facility must keep complete hospice care plan on file

Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The facility did not maintain a current hospice plan of care for R1. R2 or R3. The care plans for all 3 residents were obtained from the hospice agencies during the visit.DEFICIENCY CLEARED

87458 Medical Assessment (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis...other medical conditions which would preclude care of the person by the facility.This requirement is not met as evidenced by: LPA found that R6's medical assessment form LIC602A did not include the resident's primary or secondary diagnosis. This poses a potential health, safety, and personal rights risk to residents in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by: LPA found steak knife out on the counter in the kitchen of the third floor, unsupervised. LPA Malia Thao observed food service staff walk out of kitchen/dining room, then LPAs entered kitchen/dining area with LVN Faith Enriquez and observed steak knife out on counter. While touring the memory care unit, LPAs observed from the hallway, a disinfecting spray bottle on top of toilet tank in Room 244. Room 244's door was open, and disinfecting spray was accessible to room's resident as well as all other passing residents. This poses an immediate health, safety, and personal rights risk to residents in care.

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment.. both of which shall include a reassessment of the resident’s dementia care needs.This requirement is not met as evidenced by: LPA found that R2 is diagnosed with dementia and last had a medical assessment completed on 2/20/2020. This poses a potential health, safety, or personal rights risk to residents in care.

Limit staff assistance with self-administered drugs

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(5) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: LPAs found that the facility staff were not administering medication as prescribed. R1's medication Acetaminophen 325mg tablet was started on 10/29/21 as a routine medicine to be given two tablets by mouth every 8 hours for pain. Starting from 10/29/21 to today, only 9 doses have been administered, but 7 doses were remaining on the bubble pack card not given as prescribed. All doses for 10/29/21 through 10/31/21 were given. Doses for 11/1/21 through 11/3/21 AM dose were not given and still in the bubble pack card. This poses an immediate health, safety, or personal rights risk to residents in care.

§1569.312 Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services: (b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents.This requirement is not met as evidenced by: LPA found that 3 out of 8 residents sampled showed Activities of Daily Living (ADL) logs did not match the residents basic services as shown on the residents' Physician's Report for Residential Care Facilities for the Elderly form LIC602A. This poses a potential health, safety, or personal rights risk to residents in care.

Right to freedom from abuse and neglect

Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation...This requirement is not met as evidenced by: During the course of the investigation, facility self reported S1 was found to have financially abused R1. S1 admitted to receiving checks from R1. This poses a potential personal rights risk to residents in care.

Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase;...(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs,...This requirement is not met as evidenced by: During the course of the investigation, LPA found that facility increased R1’s monthly fee due for January and February 2021 without the proper advance written notice of 60 days. This poses a potential personal rights risk to residents in care.