Rosewood Post Acute
1911 Oak Park Boulevard · Pleasant Hill, CA · 94523 · 9259356630
113 certified beds For profit - Corporation Chain: Windsor
Why this verdict
- Carries CMS’s abuse warning icon.
- Staffing hours comfortably above national benchmarks.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.46 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.10 | 0.55–0.75 |
| Weekend hours / resident-day | 4.31 | ≈ weekday level |
| Nursing turnover / year | 35% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (35 in the current record)
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Potential for harm · D March 2, 2026 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected March 16, 2026 · Resident Rights
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Potential for harm · D March 2, 2026 · found via complaint
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected March 16, 2026 · Resident Rights
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Potential for harm · D February 17, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 24, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 5, 2026 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected January 29, 2026 · Resident Rights
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Potential for harm · D December 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 22, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 20, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected June 23, 2025 · Resident Rights
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Potential for harm · D February 28, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected March 7, 2025 · Resident Rights
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Potential for harm · E February 28, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 7, 2025 · Quality of Life and Care
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Potential for harm · E February 28, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected March 7, 2025 · Quality of Life and Care
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Potential for harm · D February 28, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected March 7, 2025 · Pharmacy Service
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Potential for harm · E February 28, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 7, 2025 · Nutrition and Dietary
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Potential for harm · E February 28, 2025
Provide and implement an infection prevention and control program.
Corrected March 7, 2025 · Infection Control
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No harm found · B February 28, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected March 7, 2025 · Environmental
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Potential for harm · D August 9, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 28, 2024 · Quality of Life and Care
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Potential for harm · D August 9, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 28, 2024 · Quality of Life and Care
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Potential for harm · D July 24, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 24, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 24, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected August 24, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 28, 2023
Ensure each resident receives an accurate assessment.
Corrected October 19, 2023 · Resident Assessment and Care Planning
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Potential for harm · E September 28, 2023
Ensure medication error rates are not 5 percent or greater.
Corrected October 19, 2023 · Pharmacy Service
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Potential for harm · E September 28, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected October 19, 2023 · Pharmacy Service
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Potential for harm · F September 28, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 19, 2023 · Nutrition and Dietary
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No harm found · B September 28, 2023
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected October 19, 2023 · Environmental
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Potential for harm · D March 12, 2020
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected April 10, 2020 · Resident Rights
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Potential for harm · E March 12, 2020
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected April 10, 2020 · Resident Rights
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Potential for harm · D March 12, 2020
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected April 10, 2020 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056476 · certified since July 1, 1977. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.