Health inspection·December 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a noncompliance care plan (CP- documents the resident's needs based on an identified problem, documents interventions necessary to be implemented by the whole healthcare team to meet the established goal) for one of three sampled residents (Resident 1) identified as a high risk for developing pressure injuries (PI-is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure resulted in Resident 1 developing an unstageable pressure injury (obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the PI cannot be confirmed because it is obscured by slough [yellow or white material consisting of dead cells which attaches to the wound bed] or eschar [dead tissue that forms over healthy skin]. If slough or eschar is removed, a Stage 3 [Full-thickness loss of skin, in which adipose (fat) is visible] or Stage 4 [Full-thickness skin and tissue loss with exposed muscle, tendon [flexible tissue, similar to a rope], ligament [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects joints and bones] or bone are visible in the pressure injury] are revealed) to the coccyx (tailbone) and a deep tissue injury (DTI intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) to the right heel. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included wedge compression fracture of T-9 and T-10 vertebra (is a break in a vertebra [bones in your spine]) and end stage renal disease (kidney disease that progresses to a point where the kidneys lose nearly all their ability to filter waste from the body). During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 8/11/25, the MDS indicated, Resident 1' s BIMS (Brief Interview for Mental Status-standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness) The MDS indicated Resident 1 was dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), and sit to lying (the ability to move from sitting on side of bed to lying flat on the bed). The MDS indicated Resident 1 did not have pressure injuries upon admission. The MDS indicated Resident 1 was at risk for developing pressure injuries. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, (Braden) dated 8/26/25, the Braden indicated Resident 1 scored a 11 (score of 10-12 indicated resident 1 was at a high risk for developing a pressure injury). During a review of Resident 1's Clinical admission (CA), dated 8/26/25, the CA indicated, Page 1 of 4 555116 555116 12/10/2025 Rosewood Health Facility 1401 New Stine Road Bakersfield, CA 93309

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Skin: Skin warm & dry, Skin color WNL (within normal limits) and turgor (the skin's elasticity and its ability to return to normal after being gently pinched, serving as a key indicator for assessing hydration) is normal. Skin note: open scabs to R (right) lateral (towards the side of the body or away from the middle) thigh, scabs to BLE (bilateral [both sides] lower extremities [arms and legs]) and BUE (bilateral upper extremities), skin peeling to R (right) foot, old amputation (surgical removal of a limb or body part) of all digits (toes) to R (right) and L (left) foot. During a review of Resident 1's care plan (is a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on The resident has an ADL self-care performance deficit r/t (related to) Limited Mobility, Limited ROM, Musculoskeletal impairment . , initiated 8/21/25, The care plan indicated a few of the interventions were Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed 3-4 times a shift and as necessary, The resident is bedfast all or most of the time, and Personal Hygiene/Oral Care: The resident is totally dependent on 1 staff for personal hygiene and oral care. During a review of Resident 1's care plan with the focus on The resident has risk of potential for pressure injury development r/t immobility, initiated 8/22/25. The care plan indicated a few of the interventions were to The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested, Monitor nutritional status. Serve diet as ordered. Monitor intake and record. and Treat pain as per orders prior to treatment/turning. to ensure The [sic] resident's comfort. During a review of Resident 1's Documentation Survey Report, (DSR) for September 2025, the DSR indicated the following: On 9/2/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/2/25 at 11 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/2/25 at 11 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/3/25 at 1 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/3/25 at 3 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/3/25 at 5 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/4/25 at 3 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/4/25 at 5 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 9 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 5 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 7 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 9 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/6/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/6/25 at 9 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/7/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 1 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 3 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 5 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 11 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/9/25 at 1 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/1/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/1/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/2/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/3/25 at 8 a.m. the DSR indicated Resident 1 refused breakfast.On 9/3/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/3/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/4/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/5/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/5/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/7/25 at 8 a.m. the DSR indicated Resident 1 ate 26-50% of his breakfast.On 9/7/25 at 12 p.m. the DSR 555116 Page 2 of 4 555116 12/10/2025 Rosewood Health Facility 1401 New Stine Road Bakersfield, CA 93309

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 1 ate 26-50% of his lunch.On 9/7/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of his dinner.On 9/8/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/8/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner. During a review of Resident 1's Health Status Note, (HSN) dated 8/29/25 at 1:15 p.m. the HSN indicated, Resident refused turning and refused nail care notified to the nurse. Educate resident for hygiene and importance of turning to avoid pressure wounds. During a review of Resident 1's HSN, dated 8/29/25 at 10:27 p.m. the HSN indicated, Resident refused turning and nail care and change brief last round notify the nurse. Explained risk and benefits x [times] 3. During a review of Resident 1's HSN, dated 8/30/25 at 9:30 p.m. the HSN indicated, Resident refused bath Explained risk and benefits x3. During a review of Resident 1's HSN, dated 9/3/25 at 10:45 p.m. the HSN indicated, Ate 50%or less for 2 or more meals in the day. During a review of Resident 1's HSN, dated 9/4/25 at 9:06 a.m. the HSN indicated, During Night shift, resident had large BM [bowel movement] but refusing to change brief from CNA. CNA notified (sic) to CN [charge nurse]. Writer with 2 CNA go to resident. Explained resident to get brief change for hygienic purpose. Resident showing Aggressive behavior and don't want change anyway. Notified to MD [medical doctor]. Family made aware. Endorse to morning shift. During a review of Resident 1's HSN, dated 9/5/25 at 10:19 p.m. the HSN indicated, Ate 50% or less for 2 or more meals in the day. During a review of Resident 1's SBAR (situation background, appearance, review and notify- structured communication tool used in healthcare to convey critical patient information clearly and concisely) Communication Form, (SBAR) dated 9/6/25, the SBAR indicated, Other change in condition: open area on (Resident 1) scrotum (a pouch of skin containing testicles) and coccyx (tailbone) area wound unstageable . upon assessment noted pressure ulcer on coccyx . During a review of Resident 1's SBAR, dated 9/9/25, the SBAR indicated, Resident 1 had a right heel deep tissue injury (DTI - intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]). During a review of Resident 1's Skin & Wound Evaluation, (SWE) dated 9/9/25, the SWE indicated Resident 1 had an unstageable pressure injury to the sacrococcygeal, acquired in-house. The SWE indicated Resident 1's unstageable pressure injury to the sacrococcygeal measures area 1.9 cm2, length 2.5 cm, and width 1.2 cm. The SWE indicated Resident 1 was placed on a low air loss mattress and a ROHO cushion. During a review of Resident 1's SWE, dated 9/9/25, the SWE indicated, Resident 1 had a DTI pressure injury to right heel, acquired in-house. The SWE indicated Resident 1's DTI pressure injury to right heel measured area 8.3 centimeters squared (cm2- unit of measure) length 3.7 cm width 3.1 cm. The SWE indicated Resident 1 was placed on a low air loss mattress and heel protectors. During an interview on 12/8/25 at 2:59 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated some of the interventions for residents at risk for PI were to make sure to keep them clean and dry, turn every two hours and as needed, try to encourage the resident to get out of bed and go to activities. CNA 1 stated when a resident refuses, he stated try to encourage the resident or get someone to explain why the intervention is important but when the resident continues to refuse, he reports the resident's refusal to the nurse. CNA 1 stated he documents the interventions completed and refused on the POC (Point of Care - electronic charting system). During an interview on 12/8/25 at 3:24 p.m. with Registered Nurse (RN) 1, RN 1 stated for new admission she does a head toe assessment to check for skin issues. RN 1 stated the CNAs assess the resident's skin daily. RN 1 stated when the CNA report resident's refusal of interventions, she will speak to the resident to see why they are refusing, give risk and benefits of refusing the intervention. RN 1 stated she will give the risk and benefits three times. RN 1 stated 555116 Page 3 of 4 555116 12/10/2025 Rosewood Health Facility 1401 New Stine Road Bakersfield, CA 93309

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident has the right to refuse. RN 1 stated she document she spoke to the resident and gave the risk and benefits in progress note. RN 1 stated if the resident continues to refuse, she informs the residents medical doctor and the resident's family and updates care plan. During a concurrent interview and record review, on 12/8/25 at 3:37 p.m. with Director of Nursing (DON), Resident 1's CA' dated 8/26/25. DON stated Resident 1 did not have PI upon admission on [DATE]. Resident 1's SWE, dated 9/9/25 were reviewed. DON stated Resident 1' unstageable sacrococcygeal and DTI to right heel were acquired in the facility. Resident 1's DSR, dated September 2025 was reviewed. DON confirmed Resident 1's multiple refusal to turn and reposition over an eight-day period. Resident 1's care plans were reviewed. DON stated Resident 1 was at risk for PI and was totally dependent on facility staff for turning and repositioning and toileting, requiring one to two staff to assist him with turning and repositioning and toileting. DON confirmed Resident 1 did not have a care plan that addressed his refusal to turn and reposition. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . 9. Care plan interventions are chosen only after data gathering proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 555116 Page 4 of 4