Inspection·February 11, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Interdisciplinary team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) met to discuss if one of three sampled residents (Resident 1) who was high risk for falls (move downward, typically rapidly and freely without control from a higher to a lower level), had a history of falls, and had a diagnosis of Dementia (a progressive state of decline in mental abilities), was safe to have one-on-one monitoring (1:1- a type of care where a healthcare professional provides constant supervision to a resident) discontinued. After discontinuing the 1:1 monitoring the facility failed to conduct a fall risk assessment (medical evaluation used to determine how likely a resident is to fall), update the care plan (CP- a document that outlines a resident's needs, treatment, and expected outcomes) to include updated interventions, and provide adequate supervision. These failures resulted in Resident 1 sustaining a fall with fracture (broken bone), experiencing pain and requiring admission with surgical intervention (a medical procedure that involves physically altering the body to treat or prevent a medical condition) at the acute hospital. Findings: During a review of Resident 1's admission RECORD (AR), dated 2/11/25, the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had diagnosis of history of falling, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia, and spinal stenosis (a narrowing of the spinal column that occurs over time and can put pressure on the spinal cord [a tube-shaped bundle of nerves that runs from the brain to the lower back]) lumbar region (lower back) with neurogenic claudication (a condition that causes pain, weakness, or numbness in the legs while walking or standing), need for assistance with personal care, and difficulty in walking. During a review of Resident 1's admission Minimum Data Set (MDS- an assessment tool) under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns]), dated 1/13/25, the BIMS indicated, Resident 1 had a score of 3 (very low level of cognition [how well a person thinks, remembers, and learns] function). The MDS under the section GG (an assessment of the level a care a resident required), dated 1/13/25, the GG indicated, Resident 1 required supervision or touching assistance to move from a sitting to standing position, move from chair to bed or bed to chair, pick up objects from the floor from a standing position due to medical condition and/or safety concerns. During a review of Resident 1's Fall Risk Evaluation (FRE), dated 1/9/25, the FRE indicated, Resident 1 had a score of 19 (high risk for falls). (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555116 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Health Facility 1401 New Stine Road Bakersfield, CA 93309 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)