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 Rosewood Post Acute Rehabilitation : Services Summary
 
Summary

This is your complete facility information. You may print this page for your records. It is divided into two sections: the first is from State and Federal Sources. The second section is derived from Surveys conducted with the Nursing Homes in California and is their information. Every effort has been made to ensure the accuracy of this information. Inconsistencies may be present due to the nature of the varied sources.

Section 1

1. Overview
Rosewood Post Acute Rehabilitation
6041 Fair Oaks Blvd.
Carmichael , CA 95608
(916) 483-8103 
Type:   SNF 
Capacity:   
112 
Medi-Cal:   yes  
Medicare:   yes 
 

2. Citations

Citations

2011 
2012 
2013 
2014 
2015 
AA
0
0
1
0
0
A
0
0
0
0
0
B
1
1
1
0
0
Class AA:
The most serious violation, AA citations are issued when a patient death has occurred due to nursing home regulation violations, and carry fines of $25,000 to $100,000.
Class A:
Class A citations are issued when violations present imminent danger to patients or the substantial probability of death or serious harm, and carry fines from $2,000 to $20,000.
Class B:
Class B citations carry fines from $100 to $1000 and are issued for violations which have a direct or immediate relationship to health, safety, or security, but do not qualify as A or AA citations.

description of each citation
date
class
canhr category type
DHS category
fine
11/13/2013  AA  Medication  Medication 

  $100,000.00

 

A female resident was admitted to the facility on 12/15/06 for rehabilitation following femur fracture surgery. She was prescribed Warfarin, a blood thinning medication, and ordered to receive periodic blood tests to ensure her blood to clot ratio was therapeutic. On 12/18/06, the resident's applicable blood test was 2.09, within the reference range of 2-3. By 12/26/06, the measure had jumped to 5.48, which is a "high panic" result. There was no evidence the facility staff informed the resident's physician. On 1/1/07, the resident became nonresponsive and was rushed to the hospital. Her blood test measure was over 13. She was diagnosed with bleeding in the brain and died that day. Facility records showed that the resident's Warfarin had not been given from 12/26 to 12/30 but no reason was given. Nurses interviewed shortly after the resident died stated they had given Warfarin to the resident in those days. The records may have been altered. The facility was cited for failing to develop a care plan, failing to notify the doctor of the dangerous blood levels, and maintaining records to professional standards. Citation # 030010256.

10/23/2013  Elopement  Patient Care 

  $1,000.00

 

On 10/23/10, the SheriffÌs Department returned an elderly man with cognitive impairment to the facility after finding him attempting to cross a street in his wheelchair. Facility staff did not see the resident leave the building and were unaware that he was missing until he was brought back to the facility. The resident was admitted with a diagnosis of altered mental status, and his care plan instructed facility staff to ÏBe Alert regarding residentÌs whereabouts.Ó The facility was cited for failing to ensure that the resident received adequate supervision to prevent him from leaving the facility. Citation # 030010206.

12/20/2012  Fall Injury Patient Care  Patient Care 

  $1,000.00

 

On 10/27/09, a resident suffered a broken tibia when a CNA attempted to transfer her from the wheelchair to the bed without assistance from another staff member or a lifting device. The facility was cited for failure to provide adequate assistance during a transfer. Citation # 030009612.

06/20/2011  Transfer  Transfer 

  $1,000.00

 

The facility was cited for failing to ensure that the resident was not discharged to a lower level of care when his condition had not improved sufficiently that he no longer needed the services provided by the facility. They also failed to ensure the clinical record documented evidence that the resident's condition improved, and that the resident received sufficient preparation and orientation for a safe transfer. Citation # 030008315.

09/08/2010  Physical Environment Fall Injury Supervision  Patient Care 

  $20,000.00

 

On 11/08/08, an 86-year-old resident struck his head and broke his neck after his wheelchair tipped over. The facility had earlier determined that the light weight wheelchair was unsafe but continued using it. Another resident who witnessed the fall reported the victim was "propelled out of the wheelchair and he hit the wall. He was curled in fetal position crying for a doctor." On 11/13/08, five days after his fall and progressively worse complaints of pain, the resident was sent to the emergency room at the insistence of his family. The hospital found the neck fracture, treated him for seven days, and discharged him back to the facility with a neck brace. His son reported that his father then deteriorated and suffered from pneumonia and severe pain from bedsores. His son issued a statement: "I believe that if he had not been placed in that faulty wheelchair which was the cause of his injury... AND the inadequate oversight of the injury and the lack of care for him... he could have had many more days/months of a better life." The resident died on 04/22/09. The facility was cited because it failed to provide a safe environment. Citation # 030007554.

09/08/2010  Patient Care Careplan  Patient Care 

  $800.00

 

The facility was cited for failing to ensure an ongoing assessment of the patient's needs, and to ensure the patient's plan of care was reviewed, revised and updated to reflect the patient's needs. On 12/13/08, ER records documented that upon admission, the resident's catheter was improperly placed resulting in trauma with bleeding, obstruction of drainage and lack of urinary flow. Citation # 030007555.

11/30/2008  Mandated Reporting Physical Abuse  Abuse 

  $1,000.00

 

A large handprint shaped bruise was discovered on a residentÌs left hip on 8/31/07. A CNA explained that she pushed on the residentÌs hip when she was turning the resident and that may have caused the bruise. The DON could not substantiate how the bruise occurred, so she did not report the incident to the Department. The facility was cited for failing to report the family memberÌs allegation of abuse as required. Citation # 030004414.

03/29/2007  Fall  Patient Care 

  $1,000.00

 

On 8/21/05, staff found a resident who had fallen in the bathroom. Nurses' notes indicated that she was treated for a skin tear on her elbow with "no other injuries." The resident complained of continual pain. The facility waited at least 43 hours before sending her to the hospital where it was determined that she had a hip fracture. The facility was cited for failure to ensure that the resident received the required ongoing assessments after she had fallen. Citation # 030003793.

03/29/2007  Decubiti (Bedsores)  Patient Care 

  $1,000.00

 

On 2/20/07, a resident was hospitalized for treatment of grossly infected Stage IV bedsores. The facility did not provide needed wound care during the prior 10 days, during which time the bedsores developed an odor "so foul and prominent it escaped the room and penetrated the halls causing a persistent foul smell..." The facility was cited because its failures resulted in the resident's Stage IV bedsores becoming re-infected. Citation # 030003859.

11/04/2005  Medication  Medication 

  $14,000.00

 

On 7/12/05, an LVN failed to document that a 75 mcg Duragesic patch (opioid pain medicine) had been administered to a resident. As a result, 75 mcg more of Duragesic patches were administered. The resident normally received just 75 mcg of Duragesic every 72 hours. The resident became unresponsive and was transferred to an acute facility for eight days. The facility was cited for failing to administer medication as prescribed by the physician, and failure to inform the RN of the residents deteriorating condition. Citation # 030002340.

05/24/2005  Physical Abuse Injury  Administration 

  $1,000.00

 

As a result of an investigation on 2/2/05, the facility was cited for failure to develop adequate interventions to prevent the occurrence of physical altercations between residents. Three documented occurrences existed, all involving one resident's physical aggression toward other residents. These occurrences included slapping one resident across the face, hitting another resident which resulted in a laceration to that resident's forehead, and throwing a water pitcher at another resident. Citation # 030002325.

08/15/1997  Physical Abuse  Patient Care 

  $500.00

 

CNA slapped resident in the eye in the middle of the night -- resident became fearful of aide -- after investigation of incident, aide was terminated -- facility cited for failing to ensure that resident was not subjected to physical abuse Citation # 030001822.

11/02/1993  Injury  Patient Care 

  $2,000.00

 

Resident's leg broken when transferred Citation # 030001488.

06/18/1993  Physical Abuse  Patient Rights 

  $2,000.00

 

Resident injured while being forced to shower Citation # 030001423.

10/23/1992  Decubiti  Patient Care 

  $8,000.00

 

Resident developed three Stage IV bedsores in two months with no intervention Citation # 030001315.

10/23/1992  Decubiti  Patient Care 

  $8,000.00

 

Facility failed to provide careplans for pressure sores, to treat them adequately or to keep signed nurses' notes on residents' treatment progress Citation # 030001316.

10/23/1992  Decubiti  Patient Care 

  $1,000.00

 

Facility failed to treat resident's bedsores and keep her free of feces Citation # 030001317.

02/07/1992  Physical Abuse  Patient Rights 

  $1,000.00

 

CNA squeezed resident's hands and wrists leaving bruises and threatened to tie the cord around resident's neck when call light was requested -- CNA fired, but facility failed to report incident Citation # 030001196.

09/19/1991  Patient Care  Patient Care 

  $800.00

 

CitationWatch description will be published once citation is received. Citation # 030001156.

05/16/1991  (dismissed)*  Other  Other 

  $0.00

 

CitationWatch description will be published once citation is received. Citation # 030001116.

04/24/1991  Patient Care  Patient Care 

  $500.00

 

CitationWatch description will be published once citation is received. Citation # 030001109.

04/16/1991  WMF/O  Patient Records  Patient Records 

  $500.00

 

CitationWatch description will be published once citation is received. Citation # 030001106.

03/11/1991  Patient Care  Patient Care 

  $5,000.00

 

CitationWatch description will be published once citation is received. Citation # 030001097.


3. Complaints
 
2011 
2012 
2013 
2014 
2015 
complaints
39
27
35
2
O
Statewide
Averages
(15.1) (16.1) (14) (14) (3.3)


date source category outcome
1/14/2014 Complaint  Infection Control  Substantiated
1/10/2014 Reported Event  Quality of Care/Treatment, Resident Safety 
12/4/2013 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Unsubstantiated
12/4/2013 Reported Event  Resident/Patient/Client Abuse, Sexual  Unsubstantiated
10/21/2013 Complaint  Resident/Patient/Client Rights, Resident Not Treated with Dignity/Respect  Unsubstantiated
10/2/2013 Complaint  Pharmaceutical Services  Unsubstantiated
10/2/2013 Complaint  Quality of Care/Treatment, Facility Staffing  Unsubstantiated
10/2/2013 Complaint  Quality of Care/Treatment  Unsubstantiated
10/2/2013 Complaint  Resident/Patient/Client Rights, Other  Unsubstantiated
9/27/2013 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
9/27/2013 Reported Event  Resident/Patient/Client Abuse, Sexual  Unsubstantiated
9/13/2013 Reported Event  Quality of Care/Treatment, Resident Safety  Substantiated
7/31/2013 Reported Event  Quality of Care/Treatment, Resident Safety  Substantiated
7/31/2013 Complaint  Quality of Care/Treatment, Resident Safety  Unsubstantiated
7/31/2013 Complaint  Quality of Care/Treatment, Resident Safety  Substantiated
7/22/2013 Complaint  Quality of Care/Treatment, Other  Substantiated
7/9/2013 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
6/24/2013 Complaint  Fraud/False Billing, Other  Unsubstantiated
6/24/2013 Complaint  Quality of Care/Treatment, Resident Safety/Falls  Unsubstantiated
6/24/2013 Complaint  Dental Services  Unsubstantiated
6/24/2013 Complaint  Quality of Care/Treatment, Other  Unsubstantiated
6/24/2013 Complaint  Quality of Care/Treatment, No Weight Loss Assessment By Facility  Unsubstantiated
6/24/2013 Complaint  Quality of Care/Treatment, Phys Not Notified of Resident Change In Condition  Unsubstantiated
6/24/2013 Complaint  Falsification of Records/Reports, Facility Medical Records Falsified  Unsubstantiated
6/24/2013 Complaint  Resident/Patient/Client Assessment  Unsubstantiated
6/24/2013 Complaint  Quality of Care/Treatment, No Pressure Sore Precautions Taken By Facility  Unsubstantiated
6/24/2013 Complaint  Quality of Care/Treatment, Inappropriate Feeding Assistance For Wt Loss Res  Unsubstantiated
6/24/2013 Complaint  Resident/Patient/Client Neglect, Assess/Monitor  Substantiated
5/24/2013 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
5/24/2013 Reported Event  Resident/Patient/Client Abuse, Sexual  Unsubstantiated
5/10/2013 Reported Event  Resident/Patient/Client Rights, Other  Substantiated
4/30/2013 Reported Event  Quality of Care/Treatment, Resident Safety  Substantiated
4/29/2013 Complaint  Quality of Care/Treatment, Facility Staffing  Substantiated
4/18/2013 Complaint  Admission, Transfer & Discharge Rights  Unsubstantiated
3/11/2013 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
3/11/2013 Reported Event  Administration/Personnel  Substantiated
1/8/2013 Complaint  Quality of Care/Treatment, Water Not Offered To Resident  Unsubstantiated
12/14/2012 Complaint  Quality of Care/Treatment 
11/14/2012 Complaint  Quality of Care/Treatment, Call Bell Not Answered Timely Manner By Staff 
10/23/2012 Complaint  Quality of Care/Treatment  Substantiated
10/1/2012 Complaint  Resident/Patient/Client Abuse, Employee to Resident 
10/1/2012 Complaint  Quality of Care/Treatment 
9/27/2012 Complaint  Resident/Patient/Client Abuse, Sexual 
9/21/2012 Complaint  Administration/Personnel 
9/10/2012 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
9/10/2012 Reported Event  Resident/Patient/Client Abuse, Sexual 
9/7/2012 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
9/5/2012 Reported Event  Quality of Care/Treatment, Resident Safety 
8/3/2012 Complaint  Quality of Care/Treatment  Substantiated
8/3/2012 Complaint  Quality of Care/Treatment, Resident Safety/Falls  Substantiated
5/14/2012 Complaint  Resident/Patient/Client Abuse, Other  Unsubstantiated
4/25/2012 Complaint  Resident/Patient/Client Abuse  Substantiated
4/19/2012 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
4/13/2012 Complaint  Quality of Care/Treatment  Unsubstantiated
4/13/2012 Reported Event  Resident/Patient/Client Abuse, Other 
3/28/2012 Complaint  Resident/Patient/Client Abuse, Other  Unsubstantiated
3/19/2012 Reported Event  Resident/Patient/Client Abuse, Other 
3/16/2012 Complaint  Quality of Care/Treatment 
3/16/2012 Reported Event  Resident/Patient/Client Abuse, Family/Visitor to Resident 
3/15/2012 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
3/12/2012 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
3/5/2012 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
2/23/2012 Complaint  Quality of Care/Treatment, Resident Safety/Falls 
2/21/2012 Complaint  Quality of Care/Treatment 
12/23/2011 Reported Event  Infection Control 
12/22/2011 Complaint  Quality of Care/Treatment 
12/20/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
12/16/2011 Reported Event  Quality of Care/Treatment 
11/23/2011 Reported Event  Resident/Patient/Client Abuse, Other 
11/22/2011 Reported Event  Resident/Patient/Client Abuse 
11/22/2011 Reported Event  Other 
11/14/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
11/14/2011 Complaint  Quality of Care/Treatment  Unsubstantiated
11/3/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
10/7/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
9/12/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
9/7/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
8/26/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
8/26/2011 Complaint  Quality of Care/Treatment  Unsubstantiated
8/17/2011 Complaint  Infection Control  Unsubstantiated
8/12/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
8/9/2011 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
8/9/2011 Complaint  Quality of Care/Treatment  Unsubstantiated
8/5/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
8/1/2011 Complaint  Restraints/Seclusion - General 
7/28/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
7/13/2011 Complaint  Quality of Care/Treatment, Resident Safety/Falls  Unsubstantiated
6/27/2011 Reported Event  Quality of Care/Treatment, Resident Safety 
6/23/2011 Complaint  Resident/Patient/Client Rights  Unsubstantiated
6/23/2011 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
6/23/2011 Complaint  Quality of Care/Treatment  Substantiated
5/19/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
5/11/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
4/15/2011 Complaint  Quality of Care/Treatment  Substantiated
4/12/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
4/7/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
3/17/2011 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
3/10/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
2/18/2011 Complaint  Admission, Transfer & Discharge Rights  Substantiated
2/7/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
2/7/2011 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
1/20/2011 Complaint  Quality of Care/Treatment  Unsubstantiated
1/20/2011 Complaint  Quality of Care/Treatment  Unsubstantiated
12/24/2010 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
12/21/2010 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
12/9/2010 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
12/8/2010 Reported Event  Resident/Patient/Client Rights, Other  Unsubstantiated
10/27/2010 Complaint  Quality of Care/Treatment, Resident Safety 
8/26/2010 Complaint  Quality of Care/Treatment, Other  Substantiated
8/18/2010 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
7/21/2010 Complaint  Quality of Care/Treatment, Resident Safety/Falls  Substantiated
7/12/2010 Complaint  Physical Environment, Safe Environment Not Provided  Unsubstantiated
6/22/2010 Complaint  Quality of Care/Treatment, Facility Staffing  Unsubstantiated
5/25/2010 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
5/6/2010 Complaint  Quality of Care/Treatment, Other  Substantiated
5/4/2010 Complaint  Admission, Transfer & Discharge Rights  Substantiated
4/15/2010 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
4/14/2010 Complaint  Quality of Care/Treatment  Unsubstantiated
4/14/2010 Complaint  Admission, Transfer & Discharge Rights  Substantiated
4/13/2010 Complaint  Quality of Care/Treatment  Substantiated
4/13/2010 Complaint  Admission, Transfer & Discharge Rights  Substantiated
3/25/2010 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
2/26/2010 Complaint  Quality of Care/Treatment 
2/24/2010 Complaint  Quality of Care/Treatment  Substantiated
2/11/2010 Complaint  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
12/4/2009 Complaint  Quality of Care/Treatment  Substantiated
12/4/2009 Complaint  Quality of Care/Treatment  Substantiated
11/18/2009 Complaint  Quality of Care/Treatment  Substantiated
11/18/2009 Complaint  Nursing Services  Substantiated
11/18/2009 Complaint  Quality of Care/Treatment  Substantiated
11/18/2009 Complaint  Nursing Services  Substantiated
11/13/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
11/13/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
11/10/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
11/10/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
10/28/2009 Complaint  Quality of Care/Treatment, Resident Safety 
10/28/2009 Complaint  Quality of Care/Treatment, Resident Safety 
10/22/2009 Reported Event  Resident/Patient/Client Abuse, Sexual  Substantiated
10/8/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
9/29/2009 Complaint  Admission, Transfer & Discharge Rights  Unsubstantiated
9/17/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
9/15/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
9/8/2009 Complaint  Quality of Care/Treatment  Substantiated
8/31/2009 Complaint  Quality of Care/Treatment  Substantiated
8/28/2009 Complaint  Quality of Care/Treatment, Resident Safety  Unsubstantiated
8/25/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
8/24/2009 Complaint  Resident/Patient/Client Rights, Resident Not Treated with Dignity/Respect  Unsubstantiated
8/12/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
7/20/2009 Complaint  Misappropriation of Property 
7/17/2009 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
7/17/2009 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
7/1/2009 Complaint  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
7/1/2009 Complaint  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
6/4/2009 Complaint  Quality of Care/Treatment, Res Meds Not Given According To Phys Instructions  Unsubstantiated
5/26/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
5/7/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
5/7/2009 Complaint  Quality of Care/Treatment  Unsubstantiated
5/4/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
4/1/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
3/25/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
3/24/2009 Complaint  Quality of Care/Treatment, Facility Staffing  Unsubstantiated
3/9/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
3/4/2009 Reported Event  Quality of Care/Treatment  Substantiated
2/6/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
2/5/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
1/5/2009 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
12/23/2008 Complaint  Quality of Care/Treatment  Substantiated
12/23/2008 Complaint  Quality of Care/Treatment  Substantiated
11/26/2008 Complaint  Misappropriation of Property 
11/13/2008 Complaint  Quality of Care/Treatment  Unsubstantiated
11/13/2008 Complaint  Quality of Care/Treatment  Unsubstantiated
10/31/2008 Reported Event  Infection Control  Substantiated
10/21/2008 Reported Event  Resident/Patient/Client Rights, Resident Not Treated with Dignity/Respect  Substantiated
10/21/2008 Reported Event  Resident/Patient/Client Rights, Resident Not Treated with Dignity/Respect  Substantiated
10/7/2008 Reported Event  Quality of Care/Treatment, Resident Safety 
9/29/2008 Complaint  Resident/Patient/Client Rights, Resident Denied Visitation/Access Rights 
9/12/2008 Reported Event  Resident/Patient/Client Abuse, Family/Visitor to Resident  Substantiated
9/11/2008 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
8/14/2008 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
8/14/2008 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
8/13/2008 Complaint  Quality of Care/Treatment  Substantiated
8/13/2008 Complaint  Falsification of Records/Reports  Unsubstantiated
7/24/2008 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
7/9/2008 Complaint  Quality of Care/Treatment  Substantiated
6/16/2008 Complaint  Quality of Care/Treatment  Unsubstantiated
6/16/2008 Complaint  Quality of Care/Treatment  Unsubstantiated
5/9/2008 Complaint  Admission, Transfer & Discharge Rights  Substantiated
5/9/2008 Complaint  Admission, Transfer & Discharge Rights  Substantiated
4/25/2008 Complaint  Physical Environment  Substantiated
4/16/2008 Reported Event  Quality of Care/Treatment, Resident Safety/Falls  Substantiated
4/10/2008 Complaint  Quality of Care/Treatment 
4/10/2008 Complaint  Falsification of Records/Reports 
4/10/2008 Complaint  Quality of Care/Treatment  Substantiated
4/10/2008 Complaint  Quality of Care/Treatment 
4/10/2008 Complaint  Falsification of Records/Reports 
4/7/2008 Complaint  Admission, Transfer & Discharge Rights 
3/10/2008 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
1/24/2008 Complaint  Resident/Patient/Client Abuse, Employee to Resident  Substantiated
1/24/2008 Complaint  Resident/Patient/Client Abuse, Employee to Resident  Substantiated
1/23/2008 Complaint  Quality of Care/Treatment, Resident Safety 
1/18/2008 Complaint  Quality of Care/Treatment 
1/10/2008 Reported Event  Injury of Unknown Origin 
1/8/2008 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Substantiated
12/27/2007 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
12/19/2007 Reported Event  Injury of Unknown Origin 
12/18/2007 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
12/14/2007 Reported Event  Resident/Patient/Client Abuse, Employee to Resident 
11/26/2007 Complaint  Quality of Care/Treatment, Other  Unsubstantiated
11/14/2007 Complaint  Administration/Personnel  Unsubstantiated
10/30/2007 Reported Event  Resident/Patient/Client Abuse, Resident to Resident 
10/15/2007 Complaint  Quality of Care/Treatment  Unsubstantiated
10/15/2007 Reported Event  Resident/Patient/Client Rights 
9/25/2007 Complaint  Physical Environment 
9/11/2007 Reported Event  Physical Environment  Unsubstantiated
9/10/2007 Reported Event  Resident/Patient/Client Rights, Resident Not Treated with Dignity/Respect 
9/4/2007 Complaint  Injury of Unknown Origin  Substantiated
8/20/2007 Reported Event  Physical Environment  Unsubstantiated
6/25/2007 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Unsubstantiated
6/18/2007 Complaint  Resident/Patient/Client Abuse  Unsubstantiated
6/6/2007 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Unsubstantiated
5/23/2007 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Unsubstantiated
5/8/2007 Complaint  Quality of Care/Treatment 
2/27/2007 Reported Event  Resident/Patient/Client Abuse, Employee to Resident  Unsubstantiated
2/27/2007 Reported Event  Resident/Patient/Client Rights, Resident Not Treated with Dignity/Respect  Unsubstantiated
2/22/2007 Complaint  Quality of Care/Treatment  Substantiated
2/13/2007 Reported Event  Resident/Patient/Client Abuse  Unsubstantiated
2/7/2007 Reported Event  Injury of Unknown Origin 
2/5/2007 Reported Event  Quality of Care/Treatment 
1/23/2007 Complaint  Resident/Patient/Client Rights  Unsubstantiated
1/22/2007 Reported Event  Infection Control  Unsubstantiated
1/22/2007 Complaint  Infection Control  Unsubstantiated
1/18/2007 Complaint  Quality of Care/Treatment, Improper Infection Control Practiced By Facility  Unsubstantiated
1/18/2007 Complaint  Infection Control  Unsubstantiated
1/18/2007 Complaint  Resident/Patient/Client Rights  Unsubstantiated
1/8/2007 Complaint  Quality of Care/Treatment  Unsubstantiated
1/4/2007 Reported Event  Quality of Care/Treatment, Resident Meds Improperly Administered 
12/21/2006 Reported Event  Resident/Patient/Client Abuse, Other  Unsubstantiated
11/20/2006 Reported Event  Resident/Patient/Client Abuse  Unsubstantiated
11/20/2006 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Unsubstantiated
11/14/2006 Complaint  Quality of Care/Treatment  Substantiated
11/8/2006 Reported Event  Quality of Care/Treatment  Unsubstantiated
8/25/2006 Reported Event  Resident/Patient/Client Abuse, Resident to Resident  Unsubstantiated
6/22/2006 Complaint  Quality of Care/Treatment  Unsubstantiated
3/20/2006 Complaint  Resident/Patient/Client Rights  Unsubstantiated
1/17/2006 Complaint  Quality of Care/Treatment  Substantiated
 

4. Deficiencies
 
summary of deficiencies by year
2011
2012
2013
2014
2015
Abuse
0
0
2
Activities
0
0
0
Administration
1
3
1
Admission
0
0
0
Assessment
0
0
0
Dental
0
0
0
Dietary
3
0
1
Environment
1
1
1
Infection Control
1
0
1
Medication
1
1
2
Nursing Services
1
0
0
Other
0
0
0
Physical Plant
11
9
5
Physician
0
0
0
Quality of Care
4
3
2
Quality of Life
1
2
1
Rehabilitative Services
0
0
0
Residents Rights
1
3
1
Staffing
0
0
0
Totals:
25
22
17


5. Federal Enforcement
 
   
   There are no Federal Actions for this facility  

6. Owners
 
Current owners — Ownership data as of 4/13/2015.
Carmichael Care, Inc. — 6041 FAIR OAKS BLVD.  — CARMICHAEL, CA  95608
relationship to facility:      Licensee
dates:   since 03/16/2001
% ownership:     100%
type of owner:        Profit Corp
Donald Laws — 3 Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Direct Owner
dates:   since 03/16/2001
% ownership:     28%
type of owner:        Individual
David Sorensen — 3 Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Direct Owner
dates:   since 03/16/2001
% ownership:     45%
type of owner:        Individual
John Sorensen — Three Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Direct Owner
dates:   since 03/16/2001
% ownership:     27%
type of owner:        Individual
Spencer Olsen — 3 Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Corporate Officer
dates:   since 09/21/2006
% ownership:     (percentage of ownership not given)
type of owner:        Individual
Timothy J. Paulsen — 3 Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Corporate Officer
dates:   since 09/21/2006
% ownership:     (percentage of ownership not given)
type of owner:        Individual
John Sorensen — Three Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Corporate Officer
dates:   since 09/21/2006
% ownership:     (percentage of ownership not given)
type of owner:        Individual
Teri Starkweather — 3 Monarch Bay Plaza, Suite 203  — Dana Point, CA  92629
relationship to facility:      Corporate Officer
dates:   since 09/21/2006
% ownership:     (percentage of ownership not given)
type of owner:        Individual

Previous owners.
Rosewood Rehabilitation Center, Inc. — 101 SUN AVENUE NE  — ALBUQUERQUE, NM  87109
relationship to facility:      Licensee
end date:   03/15/2001
start date:   11/09/1993
% ownership:   (percentage of ownership not given)
type of owner:   (not available)
Rosewood Terrace Convalescent — 6041 FAIR OAKS BLVD  — CARMICHAEL, CA  95608
relationship to facility:      Licensee
end date:   11/08/1993
start date:   04/16/1992
% ownership:   (percentage of ownership not given)
type of owner:   (not available)
Eskaton Properties, Incorporated — 5105 MANZANITA AVE.  — CARMICHAEL, CA  95608
relationship to facility:      Licensee
end date:   04/15/1992
start date:   06/30/1990
% ownership:   (percentage of ownership not given)
type of owner:   (not available)
Eskaton Corporation — 5105 MANZANITA AVE.  — CARMICHAEL, CA  95608
relationship to facility:      Licensee
end date:   06/29/1990
start date:   02/27/1988
% ownership:   (percentage of ownership not given)
type of owner:   (not available)
Mar-Lee Enterprises — 6041 FAIR OAKS BLVD.  — CARMICHAEL, CA  95608
relationship to facility:      Licensee
end date:   02/27/1988
start date:   02/26/1988
% ownership:   (percentage of ownership not given)
type of owner:   (not available)
 

Section 2
  (Information not available; a current questionnaire has not been completed).
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