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Rosewood Post Acute Rehabilitation : citations
 

about citations

Under state law, a California nursing home can receive a citation and fine for certain violations of the law. Most nursing homes do not receive citations. In a typical year, less than 40% of California's nursing homes receive citations.

Citations are only issued for serious violations. You should be concerned if a nursing home is issued multiple citations in a brief period of time. However, it is also important to look at the nature of the citation. Some citations may indicate facility-wide problems or demonstrate failures to meet a particular care need.

Citations, while serious, should also be put into perspective. A single citation does not necessarily mean that a nursing home will provide poor care. Review the facility's deficiencies and complaints, as well as enforcement actions to see if there is a pattern of violations or if the facility has a fairly good record.

A change of ownership or management can quickly change the quality of care in a facility. Look to see which citations, if any, were acquired under the current owner.

The description for each citation lists the date that it was issued, the class of the citation, the CANHR category, the DPH category, and the amount of the fine. This information is followed by a brief summary of the citation prepared by CANHR.

At the end of each citation description is a citation number. If you want a copy of the actual citation, you will need to request it by citation number. Copies of citations can be obtained at the DPH District Office in the district where the facility is located. (link to DPH L&C district offices)


Includes Citations received by CANHR as of 7/8/2015

summary of citations by year

Citations

2011 
2012 
2013 
2014 
2015 
AA
0
0
1
0
0
A
0
0
0
0
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B
1
1
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description of each citation
details
date
class
canhr category type
DHS category
fine
11/13/2013  AA  Medication  Medication 

  $100,000.00

 

Name at time: Rosewood Post Acute Rehabilitation
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

 

Name at time: Rosewood Post Acute Rehabilitation
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

 

Name at time: Rosewood Post Acute Rehabilitation
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

 

Name at time: Rosewood Post Acute Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Care & Rehabilitation
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

 

Name at time: Rosewood Terrace Convalescent
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

 

Name at time: Rosewood Terrace Convalescent
Resident's leg broken when transferred Citation # 030001488.

06/18/1993  Physical Abuse  Patient Rights 

  $2,000.00

 

Name at time: Rosewood Terrace Convalescent
Resident injured while being forced to shower Citation # 030001423.

10/23/1992  Decubiti  Patient Care 

  $8,000.00

 

Name at time: Rosewood Terrace Convalescent
Resident developed three Stage IV bedsores in two months with no intervention Citation # 030001315.

10/23/1992  Decubiti  Patient Care 

  $8,000.00

 

Name at time: Rosewood Terrace Convalescent
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

 

Name at time: Rosewood Terrace Convalescent
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

 

Name at time: Rosewood Terrace Convalescent
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

 

Name at time: Rosewood Terrace Convalescent
CitationWatch description will be published once citation is received. Citation # 030001156.

05/16/1991  (dismissed)*  Other  Other 

  $0.00

 

Name at time: Rosewood Terrace Convalescent
CitationWatch description will be published once citation is received. Citation # 030001116.

04/24/1991  Patient Care  Patient Care 

  $500.00

 

Name at time: Rosewood Terrace Convalescent
CitationWatch description will be published once citation is received. Citation # 030001109.

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

  $500.00

 

Name at time: Rosewood Terrace Convalescent
CitationWatch description will be published once citation is received. Citation # 030001106.

03/11/1991  Patient Care  Patient Care 

  $5,000.00

 

Name at time: Rosewood Terrace Convalescent
CitationWatch description will be published once citation is received. Citation # 030001097.

 

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