Other·September 9, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: 664826 Representing the Department: 39763, HFEN 42167, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint number 664826.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/02/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of four residents (Resident 1), when Resident 1 refused treatment. This failure had the potential for unmet care needs for Resident 1. Findings: During a review of Resident 1's "Physician Order Sheet" (POS), dated October 2019, the POS indicated Lactulose (medication to treatment and prevention of portal-systemic encephalopathy [the loss of brain function when a damaged liver does not remove toxins from the blood]) 10 grams (unit of measure)/ 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE milliliters (ml-unit of measure) orally, three times a day, 9 a.m., 1 p.m., and 5 p.m. Other (indication) cirrhosis of the liver (chronic liver damage causing scarring and liver failure). During a review of Resident 1's "Medication Administration Record" (MAR), dated October 2019, the MAR indicated Resident 1 had refused her Lactulose on: 10/11/19, at 9 a.m. 10/12/19, at 9 a.m., 1 p.m., and 5 p.m. 10/13/19, at 9 a.m., 1 p.m., and 5 p.m. 10/14/19, at 5 p.m. 10/16/19, at 9 a.m. and 5 p.m. 10/17/19, at 9 a.m. 10/19/19, at 1 p.m. and 5 p.m. 10/20/19, at 9 a.m. and 1 p.m. 10/21/19, at 9 a.m., 1 p.m., and 5 p.m. 10/22/19, at 9 a.m., 1 p.m., and 5 p.m. 10/23/19, at 9 a.m., 1 p.m., and 5 p.m. 10/24/19, at 9 a.m., 1 p.m., and 5 p.m. 10/25/19, at 9 a.m., 1 p.m., and 5 p.m. 10/26/19, at 9 a.m. and 1 p.m. During a concurrent interview and record review on 11/26/19, at 10:40 a.m., with Director of Nursing (DON), Resident 1's clinical record was reviewed and DON was unable to find a care plan (CP) for medication non-compliance. DON stated Resident 1 was very noncompliant. DON stated she would expect Resident 1 to have a CP for medication noncompliance. During a review of the facility's policy and procedure (P&P) titled, "Care Plans, Comprehensive Person-Centered," revised December 2016, the P&P indicated, "8. The comprehensive, person-centered care plan will: . . . b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychosocial well-being; c. Describe services that would otherwise be provided for the, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . . . g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . . . m. Aid in preventing or reducing decline in the resident's functional status and or functional levels; . . ."

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 03/02/2020 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to respond to consultant pharmacist facility notification of medication irregularity for one of four residents (Resident 1). This failure had the potential to lead to adverse outcomes for Resident 1. Findings: During a review of Resident 1's "Medication Administration Record" (MAR), dated September 2019, the MAR indicated, a physician's order for Lantus insulin (medication to treat high blood sugar) 50 units subcutaneous (a shot given into the fat layer between the skin and muscle) daily at 9 p.m. The following documentation was noted: 9/3/19, at 9 p.m., Lantus 6 units 9/9/19, at 9 p.m., Lantus 2 units 9/18/19, at 9 p.m., Lantus 4 units 9/24/19, at 9 p.m., Lantus 8 units During a concurrent interview and record review on 12/5/19, at 3:55 p.m., with Director of Nursing (DON), DON stated the consultant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pharmacist reviews the MAR every month for errors and irregularities then makes recommendations for nursing to follow up on. She reviewed Resident 1's "Pharmacy Consultants Notes For Nursing Staff", dated 9/23/19, which indicated Resident 1's MAR contained "Inconsistency in recording of Lantus insulin units administered. Some days it is recorded as 50 units, others days it is recorded as 4 units." DON confirmed consultant pharmacist identified Lantus insulin irregularity and action was not taken on the irregularities reported. She stated the previous assistant director of nursing (ADON) was in charge of conducing the follow up. DON stated, ADON did not act up on the consultant's findings. She stated ultimately it was her (DON) responsibility to ensure it was done but she entrusted it to the ADON. During a review of the facility's policy and procedure (P&P) titled, "MEDICATION REGIMEN REVIEW AND REPORTING," dated May 2016, the P&P indicated, "Medication Regimen Review (MRR) is defined as the systematic evaluation of medication therapy viewed within the context of resident-specific data. The consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations and respond to in an appropriate and timely fashion. Those with authority and responsibility include the administrator and the director of nursing . . ."

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F760 Event ID: 231M11 03/02/2020 Facility ID: CA050000369 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to administer insulin (medication to treat high blood sugar, BS) according to physician's orders for one of four sampled residents (Resident 1) when Resident 1 received a higher dose of insulin than was prescribed. This failure resulted in hypoglycemia (condition caused by a very low level of blood sugar, your body's main energy source, also adverse reaction associated with insulin. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death) for Resident 1. Findings: During a review of Resident 1's "Face Sheet" (FS), dated 11/26/19, the "FS" indicated, Resident 1 was admitted to the facility on 3/19/19. FS indicated diagnoses were diabetes (a disease in which one's blood sugar levels are too high), hepatic failure (liver failure), and cirrhosis of the liver (scaring of the liver causing decrease in function). During a review of Resident 1's "Physician's Orders" (PO), dated September 2019, the PO indicated Lantus insulin (long acting medication to treat high BS) 50 units subcutaneous (is a shot given into the fat layer between the skin and muscle) daily at 9 p.m. During a review of Resident 1's "Medication Administration Record" (MAR, a legal record of the drugs administered to a patient), dated September 2019, the MAR indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9/3/19, at 9 p.m., Lantus 6 units 9/9/19, at 9 p.m., Lantus 2 units 9/18/19, at 9 p.m., Lantus 4 units 9/24/19, at 9 p.m., Lantus 8 units During a review of Resident 1's PO, dated October 2019, the PO indicated Lispro insulin (medication use to quickly reduce the amount of sugar in the blood) subcutaneous four times daily 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. per sliding scale: BS of 151-200 give 2 units BS of 201-250 give 4 units BS of 251-300 give 6 units BS of 301-350 give 8 units BS of 351-400 give 10 units BS of 401-450 give 12 units Administer before meals and at bed time. If BS is less than 60 or more than 400 notify medical doctor (MD). During a review of Resident 1's MAR, dated October 2019, the MAR indicated the following: 10/19/19, at 9 p.m., Lispro 50 units were administered, and BS recorded was 269, 10/29/19, at 9 p.m., Lispro 50 units were administered, and BS recorded was 270. During a review of Resident 1's "Nursing Progress Note" (NPN), dated 10/30/19, the NPN indicated Resident 1 was found unresponsive at 7:55 a.m., Resident 1's BS was checked and recorded as 24. Orders for glucagon (medication to treat hypoglycemia)1 milligram and D50 (50% dextrose - medication used to treat severe hypoglycemia) intravenously (directly into the vein) medication were given. Resident 1 was then transferred to the hospital. The "Change of Condition" (COC), dated 10/30/19, indicated Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admitted to the hospital with a diagnosis of hypoglycemia. During a review of Resident 1's "ED (Emergency Department) Note", dated 10/30/19, the ED note indicated that prior to transfer Resident 1 had a BS of 24. "Patient (Resident 1) was given 250 cc (cubic centimeters- unit of measure) of D10 (10% dextrose- medication give to treat severe hypoglycemia) by paramedics which helped to increase the blood sugar to 96 and minimally helped the patient's (Resident 1) mental status." During a concurrent interview and record review on 11/27/19, at 11:38 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's MAR, dated October 2019, was reviewed. LVN 1 confirmed the MAR indicated on 10/29/19 at 9 p.m., Resident 1 had a BS of 269 she confirmed Lantus insulin 50 units and Lispro insulin 50 units were documented as administered to Resident 1 by LVN 1. LVN 1 reviewed the PO, dated October 2019, the PO indicated a sliding scale for Lispro insulin, LVN 1 stated for a BS of 270 Resident 1 should have given 6 units of Lispro insulin because it is fast acting. LVN 1 stated she did not have another nurse confirm the physician order to ensure it was the right medication and the right dose prior to administration, she stated it is not their facility's policy to do so. During a concurrent interview and record review on 11/27/19, at 12:11 p.m., with Director of Nursing (DON), Resident 1's MAR, dated October 2019, was reviewed. DON confirmed the MAR indicated a BS of 269, Lispro insulin 50 units administered on 10/19/19, at 9 p.m. was documented by LVN 2. DON confirmed the MAR indicated a BS of 270, Lispro insulin 50 units administered on 10/29/19, at 9 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documented by LVN 1. DON stated, "It (the MAR) is a legal permanent document we cannot prove otherwise. It was charted it was given, it was given." During a concurrent interview and record review on 12/5/19, at 1:21 p.m., with LVN 2, she reviewed the MAR, dated October 2019. LVN 2 confirmed the documentation, Resident 1's BS was 269 and Lispro insulin 50 units and Lantus 50 units were document as administered by her (LVN 2). She stated Resident 1 should have received 6 units of Lispro for a BS of 269. LVN 2 stated she did not have another nurse witness her insulin dose to ensure the right medication or right dose was prepared for Resident 1. LVN 2 stated, she is not required to do so. During a review of the facility's policy and procedure (P&P) titled, "Insulin Administration" revised 9/14, the P&P indicated, "Purpose- To provide guidelines for the safe administration of insulin to residents with diabetes. . . 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. . . Steps in the procedure . . . 7. Check and re-check that the type of insulin on the vial matches the type of insulin ordered. 8. Check the order for the amount of insulin. . . 12. Double check the order for the amount of insulin. . . 15. Re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered. . . Documentation . . . 2. The dose and concentration of the insulin injection. . ." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 231M11 Facility ID: CA050000369 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555116 (X3) DATE SURVEY COMPLETED 02/19/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTH FACILITY 1401 New Stine Rd Bakersfield, CA 93309 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 231M11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA050000369 (X5) COMPLETE DATE If continuation sheet 11 of 11