Rosewood Health Facility
1401 New Stine Road, Bakersfield, CA 93309 · Kern County · 79 certified beds · avg 65 residents/day · certified since Jul 9, 1979
Part of chain: HUMANGOOD (17 facilities, chain avg rating 4.5★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$8,278
Fines, last 3 years
4.91
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 11, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 21, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (47)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 12, 2026 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Dec 10, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 11, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 3, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 7, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Oct 15, 2024 | D · Potential for harm, one-off | The facility did not help residents with transportation to and from laboratory services outside the facility. · from a complaint |
| Sep 27, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| Sep 5, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Sep 5, 2024 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. · from a complaint |
| Jan 4, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Oct 30, 2023 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint |
| Feb 9, 2023 | F · Potential for harm, facility-wide | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Feb 9, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 9, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 9, 2023 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 9, 2023 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 9, 2023 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not keep the required 15 months of resident assessments in each resident's active medical record. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 21 | 0 | F |
| 2024 | 15 | 0 | F |
| 2025 | 2 | 1 | G ▲ |
| 2026 | 9 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,278, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Feb 11, 2025 | Fine | $8,278 |
| Sep 5, 2024 | Payment Denial | 32 days from Dec 5, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.91 | 4.31 | 3.95 | top 16% in California; top 15% in the U.S. |
| Registered Nurse hours | 1.04 | 0.61 | 0.69 | top 10% in California; top 14% in the U.S. |
| Weekend total nurse staffing | 4.46 | 3.90 | 3.50 | top 16% in California; top 13% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.76 | 0.51 | 0.48 | top 13% in California; top 13% in the U.S. |
| Total nursing staff turnover (%) | 24.1 | 36.7 | 45.8 | top 15% in California; top 6% in the U.S. |
| RN turnover (%) | 29.4 | 38.1 | 42.9 | top 37% in California; top 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.82, RN 1.02, weekend 4.37. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Humangood | Organization | 5% or Greater Indirect Ownership Interest | 100% | 05/01/2016 |
| Humangood Norcal | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1977 |
| Baker Tilly Advisory Group LP | Organization | ADP of the SNF | NOT APPLICABLE | 03/21/2025 |
| Baker Tilly Advisory Group, LP | Organization | ADP of the SNF | NOT APPLICABLE | 03/21/2025 |
| Baker Tilly Us LLP | Organization | ADP of the SNF | NOT APPLICABLE | 10/15/2024 |
| Baker, Judith | Individual | Corporate Director | NOT APPLICABLE | 04/25/2012 |
| Balaban, Rochelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2018 |
| Balaban, Rochelle | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2018 |
| Battison, William | Individual | Corporate Director | NOT APPLICABLE | 05/01/2016 |
| Brown, Herman | Individual | Corporate Director | NOT APPLICABLE | 05/01/2016 |
| Brown, Herman | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2016 |
| Christopherson, Joanne | Individual | Corporate Director | NOT APPLICABLE | 03/20/2025 |
| Cochrane, John | Individual | Corporate Officer | NOT APPLICABLE | 08/10/2009 |
| Cochrane, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/10/2009 |
| Dhand, Sandeep | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/09/2026 |
| Dhand, Sandeep | Individual | ADP of the SNF | NOT APPLICABLE | 03/09/2026 |
| Feller, Irene | Individual | Corporate Director | NOT APPLICABLE | 03/12/2021 |
| Ghassemi, Bethany | Individual | Corporate Officer | NOT APPLICABLE | 05/21/2019 |
| Ghassemi, Bethany | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/21/2019 |
| Gonzales, Deborah | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/25/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who is your infection preventionist, and what training do they have?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "How do you train staff to treat residents with dignity, and how do you protect residents' personal belongings?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Parkview Julian Healthcare Center | 2.6 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | |
| Valley Healthcare Center | 2.7 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | |
| The Orchards Post-Acute | 4.0 mi | Bakersfield, CA | ★★☆☆☆ | 2/5 | |
| Kern River Transitional Care | 4.2 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | |
| San Joaquin Nursing Center and Rehabilitation Cent | 4.4 mi | Bakersfield, CA | ★★★☆☆ | 2/5 | |
| The Rehabilitation Center of Bakersfield | 6.0 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | |
| Height Street Skilled Care | 6.2 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | |
| Bayshire Riverwalk Post-Acute | 6.9 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | abuse |
| Bakersfield Post Acute | 8.2 mi | Bakersfield, CA | ★☆☆☆☆ | 1/5 | |
| Arvin Post Acute | 15.8 mi | Arvin, CA | ★☆☆☆☆ | 2/5 | |
| Shafter Nursing Care | 16.8 mi | Shafter, CA | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555116.