Pleasant Hill, CA

Rosewood Post Acute

4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

1911 Oak Park Boulevard, Pleasant Hill, CA

(925) 935-6630

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

113

Certified beds

Average residents

97

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Windsor

Operator or chain grouping

Approved since

1977-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

19 facilities

Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.89

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.41

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.37

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

2.29

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

4.13

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.70

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.65

CMS adjusted RN staffing hours

Adjusted total hours

3.21

CMS adjusted total nurse staffing hours

Case-mix index

1.86

Higher values indicate more complex resident acuity

RN turnover

48%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,640

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.19

Composite VBP score used to determine payment impact.

Payment multiplier

0.9869

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.71

Baseline 22.49% · Performance 19.64% · Measure score 4.71 · Achievement 3.86 · Improvement 4.71

Healthcare-associated infections

2.35

Baseline 8.53% · Performance 7.53% · Measure score 2.35 · Achievement 1.03 · Improvement 2.35

Total nurse turnover

4.94

Performance 43.48% · Measure score 4.94 · Achievement 4.94 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.87

Baseline 3.25 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.86%
10.72%
1.1 pts worse
No Different than the National Rate · Eligible stays 48 · Observed rate 22.92% · Lower 95% interval 8.52%
Discharge to community 43.25%
50.57%
7.3 pts worse
No Different than the National Rate · Eligible stays 46 · Observed rate 21.74% · Lower 95% interval 26.67%
Medicare spending per beneficiary 1.17
1.02
0.1 pts worse
Drug regimen review with follow-up 96%
95.27%
0.7 pts better
Numerator 48 · Denominator 50
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 50
Discharge self-care score 55.17%
53.69%
1.5 pts better
Numerator 16 · Denominator 29
Discharge mobility score 51.72%
50.94%
0.8 pts better
Numerator 15 · Denominator 29
Pressure ulcers or injuries, new or worsened 2%
2.29%
0.3 pts better
Numerator 1 · Denominator 50 · Adjusted rate 1.12%
Healthcare-associated infections requiring hospitalization 7.53%
7.12%
0.4 pts worse
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 4.87%
Staff COVID-19 vaccination coverage 9.92%
8.2%
1.7 pts better
Numerator 13 · Denominator 131
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score 51.72%
56.45%
4.7 pts worse
Numerator 15 · Denominator 29
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 13.04%
25.2%
12.2 pts worse
Numerator 3 · Denominator 23

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.4
2.3
0.1 pts worse
1.9
0.5 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.9 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.8
1.6
0.2 pts worse
1.8
About the same
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 96.7%
98.5%
1.8 pts worse
93.4%
3.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 95.2% · Q4 94.3% · 4Q avg 96.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98.1%
98.2%
0.1 pts worse
95.5%
2.6 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1%
Percentage of long-stay residents experiencing one or more falls with major injury 0.3%
1.6%
1.3 pts better
3.3%
3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 3.8%
6.8%
3 pts better
11.4%
7.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.5% · Q3 3.0% · Q4 1.4% · 4Q avg 3.8%
Percentage of long-stay residents who lose too much weight 4.8%
4.1%
0.7 pts worse
5.4%
0.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.0% · Q3 6.5% · Q4 3.7% · 4Q avg 4.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 11.9%
13.7%
1.8 pts better
19.6%
7.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 13.8% · Q3 11.1% · Q4 11.8% · 4Q avg 11.9%
Percentage of long-stay residents who received an antipsychotic medication 12.4%
14.2%
1.8 pts better
16.7%
4.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 12.5% · Q3 14.0% · Q4 14.5% · 4Q avg 12.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.4%
0.4 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 6.3%
11.0%
4.7 pts better
16.3%
10 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 5.4%
10.7%
5.3 pts better
14.9%
9.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.4% · Q3 7.5% · Q4 6.5% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.3%
1.0%
0.7 pts better
1.0%
0.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.0%
1.2%
1.2 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 11.7%
10.9%
0.8 pts worse
19.8%
8.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 11.5% · Q3 14.4% · Q4 14.9% · 4Q avg 11.7%
Percentage of long-stay residents with pressure ulcers 4.8%
4.7%
0.1 pts worse
5.1%
0.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.7% · Q3 5.5% · Q4 4.4% · 4Q avg 4.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 76.6%
94.0%
17.4 pts worse
81.7%
5.1 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 74.6% · Q3 76.2% · Q4 69.2% · 4Q avg 76.6%
Percentage of short-stay residents who had an outpatient emergency department visit 22.1%
11.2%
10.9 pts worse
12.0%
10.1 pts worse
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 26.3% · Expected 13.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.5%
1.5 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 71.4%
93.2%
21.8 pts worse
79.7%
8.3 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 25.0%
23.2%
1.8 pts worse
23.9%
1.1 pts worse
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 34.2% · Expected 32.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-09-28 · Fire 2023-09-28

8 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2020-03-12 · Fire 2020-03-12

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-02-01 · Fire 2019-02-01

12 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2023-09-28

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-10-16

E · Potential for more than minimal harm 2023-09-28

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-10-16

E · Potential for more than minimal harm 2023-09-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-10-16

E · Potential for more than minimal harm 2023-09-28

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-28

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-28

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-10-16

D · Potential for more than minimal harm 2020-03-12

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2020-09-14

D · Potential for more than minimal harm 2020-03-12

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2020-09-14

D · Potential for more than minimal harm 2020-03-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-09-14

D · Potential for more than minimal harm 2020-03-12

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2020-09-14

D · Potential for more than minimal harm 2020-03-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-09-14

E · Potential for more than minimal harm 2019-02-01

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2019-05-20

E · Potential for more than minimal harm 2019-02-01

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2019-05-20

E · Potential for more than minimal harm 2019-02-01

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-05-20

D · Potential for more than minimal harm 2019-02-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-05-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-05

F584 · Resident Rights Deficiencies

Health

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 2026-01-29

D · Potential for more than minimal harm 2025-12-19

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Not marked corrected

D · Potential for more than minimal harm 2025-06-20

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-06-23

D · Potential for more than minimal harm 2024-08-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-08-09

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-07-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-08-24

D · Potential for more than minimal harm 2024-07-24

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-08-24

F · Potential for more than minimal harm 2023-09-28

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-09-28

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-09-28

F761 · Pharmacy Service Deficiencies

Health

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 2023-10-19

D · Potential for more than minimal harm 2023-09-28

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-10-19

B · Minimal harm 2023-09-28

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2023-10-19

E · Potential for more than minimal harm 2020-03-12

F584 · Resident Rights Deficiencies

Health

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 2020-04-10

E · Potential for more than minimal harm 2020-03-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2020-04-10

E · Potential for more than minimal harm 2020-03-12

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F578 · Resident Rights Deficiencies

Health

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 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-04-10

D · Potential for more than minimal harm 2020-03-12

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2020-04-10

E · Potential for more than minimal harm 2019-02-01

F761 · Pharmacy Service Deficiencies

Health

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 2019-03-01

E · Potential for more than minimal harm 2019-02-01

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-03-01

D · Potential for more than minimal harm 2019-02-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-01

B · Minimal harm 2019-02-01

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2019-03-01

B · Minimal harm 2019-02-01

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2019-03-01

Penalties and ownership

What sits behind the stars

Ownership

Windsor Norcal 13 Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 10 facilities 2007-04-01
9560 Pico LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 40 facilities 2023-06-30
Antelope Holdings I, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 16 facilities 2023-06-30
Kooturu, Sri Vardhan

Operational/Managerial Control · Individual

0% 2 facilities 2017-05-01
Newgen Administrative Services, LLC

Operational/Managerial Control · Organization

0% 17 facilities 2023-06-30
Pico Ar LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 40 facilities 2023-06-30
Robin, Aaron

5% Or Greater Indirect Ownership Interest · Individual

0% 42 facilities 2023-06-30
Robin, Aaron

Corporate Officer · Individual

0% 42 facilities 2023-08-14
Shaw, Pamela

Operational/Managerial Control · Individual

0% 35 facilities 2023-06-30
Tress, Avrohom

5% Or Greater Indirect Ownership Interest · Individual

0% 42 facilities 2023-06-30
Tress, Avrohom

Corporate Officer · Individual

0% 42 facilities 2023-08-14
Youssef, Maggie

Operational/Managerial Control · Individual

0% 1 facilities 2023-07-10

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