Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosewood Post Acute during CMS and state inspections, most recent first.
A resident’s responsible party, who is the resident’s son and a full-time physician, was notified by phone on the morning of a scheduled interdisciplinary care conference that was held later that same day, leaving him unable to attend due to short notice. The SSA documented a single morning call with a voicemail left and later recorded that the responsible party had been invited but did not attend, while also acknowledging that returned calls were typically not documented and that the responsible party’s work schedule was known. The responsible party reported ongoing difficulty getting calls returned, trouble arranging conferences at times he could attend, and not being kept informed or included in treatment decisions, despite facility policy stating that resident representatives are encouraged to participate in care planning and that meetings should be scheduled at the best time for the family.
A resident’s responsible party (RP), who works full time as a physician, was notified by voicemail on the morning of a scheduled interdisciplinary care conference that the meeting would occur later that same day, leaving him unable to attend. The SSA documented only that a message was left and acknowledged typically not charting returned calls, while the care conference proceeded with staff present and the RP noted as invited but not attending. The RP reported ongoing difficulty having calls returned, trouble getting conferences scheduled at times he could attend, and not being kept informed of the resident’s care and treatment, despite facility policy stating that residents and their representatives are encouraged to participate in care planning and that meetings should be scheduled at times suitable for the resident and family.
Two residents with severe cognitive impairment and behavioral/communication limitations were left without adequate supervision, allowing one to self-propel into another's room where the second resident struck him in the face while both were in wheelchairs. Staff later acknowledged that closer line-of-sight monitoring was needed, particularly for cognitively impaired residents, but at the time of the event the lack of effective supervision and protection led to the assaulted resident sustaining pain, redness, and swelling near the left eye despite an existing abuse prohibition policy.
A resident admitted with nonrheumatic tricuspid valve disorder did not have a completed Inventory of Personal Effects form at admission or discharge. The belongings section of the form was left blank, and required signatures from the resident or representative and facility staff were missing at both admission and discharge. This occurred despite a facility policy requiring staff to list all personal items on admission, update the list as needed, and obtain signatures to acknowledge receipt of personal property.
A resident, assessed as cognitively intact and admitted with muscle weakness, reported to a family member that an LVN hit his leg during care. The LVN denied the allegation but failed to report it to supervisors or the administrator, and no documentation or investigation was initiated as required by facility policy.
A resident with severe cognitive impairment and communication deficits developed a foul-smelling right big toe, which was documented by an RN and referred to podiatry. However, there was no documentation or recall that the responsible party was notified of this change in condition, leaving them uninformed, despite facility policy requiring such notification.
A resident with severe cognitive impairment and communication difficulties experienced a change of condition involving a foul-smelling toe, which was documented by an RN and referred to podiatry. However, there was no evidence that the responsible party was notified, as required by facility policy. Both the RN and DON confirmed the lack of documentation and notification.
The facility failed to follow physician's orders for two residents with Foley catheters, leading to unreported changes in urine character and unauthorized catheter flushes. This resulted in one resident being hospitalized for a urinary tract infection and potential risks for the other. The facility did not document or notify physicians of these changes, violating care standards.
A resident with hemiplegia, hemiparesis, and morbid obesity fell out of bed during ADL care due to inadequate supervision and lack of assistive devices. The resident required a two-person assist, but a CNA continued care alone after a student CNA left the room. The resident sustained a nasal bone fracture and facial bruising. The care plan did not specify the need for a two-person assist, despite documentation indicating this requirement.
A CNA verbally abused a resident during an altercation in an LTC facility. The resident, with a history of alcohol abuse and anxiety disorder, was concerned about another resident's distress and asked the CNA to leave the room. The CNA responded by yelling at the resident. The resident's care plan included strategies for managing verbal behaviors, which were not followed during the incident.
A facility failed to conduct reference checks for a CNA before hiring, contrary to its abuse prevention policy. This oversight was discovered after a verbal altercation between the CNA and a resident, who was admitted with alcohol abuse and anxiety disorder. The CNA, unable to hear a resident's roommate due to noise, inappropriately told the resident to 'shut the hell up.' The Director of Staff Development confirmed that while background checks were done, reference checks were not documented.
Insufficient Notice to Responsible Party for Care Planning Conference
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient notice of a care planning conference to the responsible party (RP) for one of three sampled residents, resulting in the RP not being able to participate in care planning. The resident’s son, who is the designated RP and a full-time working medical doctor, reported that the facility called him and left a message on the morning of 11/13/25 stating that a care planning conference was scheduled for later that same day. He stated he was unable to attend due to the short notice. He also reported having difficulty getting his calls returned by facility staff and being unsuccessful in the past in getting care conferences scheduled at times he could attend. He stated he was not kept informed of the resident’s care and treatment and was not included in making treatment decisions. Record review and staff interviews confirmed that Social Service Assistant (SSA) 1 attempted to contact the RP on the morning of 11/13/25, left a message requesting a return call, and documented this in a Social Service Progress Note at 9:02 a.m. The Interdisciplinary Care Conference Progress Note, entered at 2:47 p.m. the same day, listed the RP as having been invited by phone but not attending, and indicated that a copy of the care plan was refused by the resident/resident representative. SSA 1 acknowledged usually not documenting when calls were returned and knew the RP was a doctor who worked full time. The Social Services Director stated that calling the son on the same day as the care conference was short notice. The facility’s care planning policy states that residents and their representatives are encouraged to participate in care plan development and that every effort will be made to schedule care plan meetings at the best time for the resident and family, which did not occur in this instance.
Insufficient Notice to Responsible Party for Care Plan Conference
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient notice to a resident’s responsible party (RP) to allow participation in the development and implementation of a person-centered care plan. The resident’s son, who is the RP and a full-time working medical doctor, reported that he received a voicemail from the facility on the morning of 11/13/25 informing him that a care planning conference was scheduled for later that same day. Due to the short notice, he was unable to attend. He also stated he had ongoing difficulty getting his calls returned by facility staff and had been unsuccessful in the past in getting care conferences scheduled at times he could attend, and that he was not kept informed of the resident’s care and treatment. Interviews and record reviews showed that the Social Service Assistant (SSA) called the RP on the morning of 11/13/25, left a message, and documented in a Social Service Progress Note that there was no answer and a message was left requesting a return call. The SSA stated that returned calls were usually not documented in the chart. A Progress Note from later that same day documented that an Interdisciplinary Care Conference was held, listed the staff attendees, and indicated that the son/RP was invited by phone but did not attend, and that a copy of the care plan was refused by the resident/resident representative. The Social Services Director acknowledged that calling the RP on the same day as the care conference was short notice. The facility’s care planning policy stated that residents and their representatives are encouraged to participate in care plan development and that every effort will be made to schedule care plan meetings at the best time for the resident and family.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Facial Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the face. One resident with dementia, who was rarely/never understood, had memory problems, and never/rarely made decisions regarding daily tasks, was able to self-propel his wheelchair independently and was known by staff to be confused and to enter other residents' rooms. On the day of the incident, this resident wheeled himself along the hallway and into another resident's room without apparent staff intervention or monitoring to prevent unsafe interactions. A restorative nurse assistant, who was with another resident at the time, heard yelling, rushed to the room, and observed the second resident swinging his arm and hitting the first resident on the left side of his face while both were in their wheelchairs. The second resident had diagnoses including anxiety and aphasia and a BIMS score of 0/15, indicating severe impairment in memory and thinking. Progress notes documented that this resident physically struck the other resident in the left eye and was angry and refused to speak with staff about the incident. Progress notes for the injured resident documented mild pain to the left eye and surrounding area, with redness and mild swelling. A nurse later stated that the incident could have been avoided by ensuring the injured resident was kept in line of sight, and emphasized that residents with severe cognitive impairment are a vulnerable population requiring protection from abuse. The facility’s abuse prohibition policy defined physical abuse as including hitting, but the incident occurred despite this policy, resulting in the resident sustaining pain, swelling, and redness near the left eye after being hit by another resident.
Failure to Complete Resident Personal Belongings Inventory at Admission and Discharge
Penalty
Summary
The facility failed to complete a personal belongings inventory for one sampled resident, resulting in an inaccurate record of the resident's possessions. The resident was admitted with diagnoses including nonrheumatic tricuspid valve disorder and later discharged home. A review of the admission record showed that, at the time of admission, the Inventory of Personal Effects form for this resident was not filled out. During an interview and concurrent record review, the Administrator confirmed that the Inventory of Personal Effects form for this resident had not been completed. Further review of the Inventory of Personal Effects form showed that the section listing the resident's personal belongings was blank, and the Certification of Receipt sections for both admission and discharge contained no signatures from the resident or resident representative, nor from a facility staff representative. Review of the facility's policy and procedure titled "Resident's Personal Property" indicated that personnel are required to identify and record resident belongings upon admission, list all items on the Inventory of Personal Effects form, keep the form in the clinical chart, add any additional items brought in after admission, and obtain signatures from the resident or representative and an employee at admission and again at discharge. These required steps were not carried out for this resident.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
A resident, who was cognitively intact and admitted with muscle weakness, reported to a family member that a Licensed Vocational Nurse (LVN) hit his right leg while assisting him back to bed. The family member confronted the LVN, who denied the allegation, but the incident was not documented in the resident's departmental notes. The LVN later acknowledged being aware of the accusation but did not report the alleged abuse to her supervisor or the facility administrator, as required by the facility's abuse policy. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported within 24 hours and investigated within 2 hours, with thorough documentation. However, the LVN failed to follow these procedures, resulting in the incident not being reported or investigated in a timely manner. The administrator confirmed that the LVN should have reported the allegation, and a review of facility records showed no documentation or investigation of the alleged abuse.
Failure to Notify Responsible Party of Resident's Change of Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change of condition as required by policy. The resident, who had a cognitive communication deficit and aphasia, was admitted with severe cognitive impairment as indicated by a BIMS score of 0. On a specific date, a registered nurse documented that the resident's right big toe had a foul smell and planned to refer the resident to podiatry. However, during a subsequent review, both the Director of Nursing (DON) and the RN were unable to find documentation that the RP had been informed of this change in condition. The RN also could not recall notifying the RP about the issue with the resident's toe. Interviews with the DON confirmed that facility policy requires immediate notification of the physician and the RP in the event of a change of condition. Review of the facility's policy and procedure further supported this requirement, stating that residents, family, legal representatives, and physicians must be informed of significant changes in the resident's physical, mental, or psychosocial status. The lack of documentation and recall regarding notification resulted in the RP being uninformed and unaware of the resident's change of condition.
Failure to Notify Responsible Party of Resident's Change of Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change of condition. The resident, who had a cognitive communication deficit and aphasia, was admitted with severe cognitive impairment as indicated by a BIMS score of 0. On a specific date, a registered nurse documented that the resident's right big toe had a foul smell and that a referral to podiatry would be made. However, there was no documentation that the RP was informed of this change in the resident's condition. During interviews and record reviews, both the RN and the Director of Nursing (DON) were unable to find evidence that the RP had been notified about the resident's condition. The RN could not recall informing the RP, and the DON confirmed that facility policy requires notification of the physician and RP in the event of a change of condition. The facility's policy also specifies that residents, family, legal representatives, and physicians must be informed of significant changes in condition or treatment needs.
Failure to Monitor and Report Changes in Foley Catheter Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for two residents, Resident 2 and Resident 3. For Resident 2, the facility did not follow physician's orders to monitor the Foley catheter urine output and failed to report changes in urine character to the physician. This oversight led to Resident 2 being transferred to the hospital with a urinary tract infection requiring intravenous antibiotics. The facility's records showed that there were multiple instances of missing documentation regarding urine character monitoring, and the attending physician was not notified of the observed changes. Similarly, for Resident 3, the facility did not adhere to physician's orders to monitor the Foley catheter urine output and failed to report changes in urine character to the physician. The records indicated that Resident 3's urine had sediment and cloudiness, and a foul smell was observed over several days, yet these changes were not communicated to the physician. Interviews with staff revealed that the presence of sediments and bloody urine should have prompted physician notification, but this was not done. Additionally, the facility performed Foley catheter flush/irrigation without a physician's order for both residents. This action was not documented in the treatment administration records, and there was no written order for the flush. The facility's policy required specific documentation for catheter irrigation, which was not followed. These failures in adhering to physician orders and facility policies had the potential to contribute to the development of urinary tract infections in the residents.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for a resident who required a two-person assist during Activities of Daily Living (ADLs). The resident, who was admitted with conditions including hemiplegia, hemiparesis, morbid obesity, and weakness, fell out of bed during ADL care, resulting in a nasal bone fracture and facial bruising. The resident's Minimum Data Set indicated an intact cognitive status, and the resident reported falling on her face due to the absence of a bed rail to hold onto during repositioning. During the incident, a Certified Nursing Assistant (CNA) was providing ADL care with a student CNA, who left the room at the resident's request. The CNA continued the care alone, despite knowing the resident required a two-person assist, and turned away to grab a towel when the resident rolled over and fell. The CNA admitted to not informing the Licensed Vocational Nurse (LVN) about the student CNA's departure and was unaware of the lack of side rails on the bed. The resident's care plan indicated the need for a positioning bar/rail in bed but did not specify the requirement for a two-person assist with bed mobility, as documented in the Weekly Summary Documentation. The facility had previously conducted in-service education for CNAs on providing two-person assistance for residents with similar needs, which the CNA involved in the incident had attended. The incident was documented in the resident's progress notes and reviewed by the Interdisciplinary Fall team, highlighting the need for maximum assistance for the resident's ADLs.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a Certified Nursing Assistant (CNA) yelled at a resident during a verbal altercation. The incident involved a resident who was admitted with diagnoses of alcohol abuse with intoxication and anxiety disorder. The resident had a Brief Interview for Mental Status (BIMS) score indicating intact cognitive status. During the incident, the CNA entered the room to assist another resident who was hollering and crying. The first resident, concerned about the situation, instructed the CNA to leave the room and get the charge nurse. In response, the CNA yelled at the resident, telling them to "shut the hell up." The resident's care plan included interventions for verbal behaviors toward staff, such as allowing time for expression of feelings and providing empathy, encouragement, and reassurance. The care plan also advised staff to postpone care activities if the resident became combative or resistive and to remove the resident from the environment if needed, while speaking in a calm, reassuring voice. Additionally, another care plan for the resident's history of verbal outbursts directed toward others recommended providing a calm, quiet, well-lit environment. These interventions were not followed during the incident, leading to the verbal altercation and the deficiency.
Failure to Conduct Reference Checks for CNA
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse by not conducting a reference check on a Certified Nursing Assistant (CNA) prior to hiring. This oversight was identified during a review of the CNA's employee files, which showed that although the CNA had listed two previous employers, no reference checks were conducted. The Director of Staff Development confirmed that while background screenings were performed, reference checks were not documented, which was contrary to the facility's policy titled 'Abuse Prohibition & Prevention and Reporting Reasonable Suspicion of a Crime in the Facility.' This policy, last revised in August 2022, required the facility to review prospective employees' employment history and check information from previous or current employers. The deficiency was highlighted during an incident involving a resident who was admitted with diagnoses including alcohol abuse with intoxication and anxiety disorder. The resident, while intoxicated, had a verbal altercation with the CNA, who responded inappropriately by telling the resident to 'shut the hell up.' This incident occurred when the CNA was attempting to assist the resident's roommate, who was hollering and crying. The CNA admitted to yelling at the resident due to the inability to hear the roommate over the noise. This situation underscored the potential risk of exposing residents to staff who may have a propensity for abusive behavior due to the lack of proper reference checks.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 533 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pleasant Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Hill Post Acute | 0.5 mi | — | 0 | 0 |
| La Casa Via Transitional Care Center | 1.8 mi | — | 0 | 0 |
| Tampico Healthcare Center | 1.9 mi | — | 3 | 0 |
| Concord Post Acute | 2.7 mi | — | 4 | 0 |
| Shadelands Post Acute | 2.7 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rosewood Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.