Rosewood Health Facility

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on March 20, 2026.

• Citation F0558. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on March 20, 2026.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for F0658 2 times since 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for F0880 3 times since 2023.

• Citation F0881. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on March 20, 2026.

• Citation F0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on March 20, 2026.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on March 20, 2026.

  CMS has cited this home for F0557 2 times since 2024.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on March 20, 2026.

• Citation F0867. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on March 20, 2026.

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CMS lists this as a standard inspection.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on February 27, 2026.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on February 26, 2026.

• Citation K0711. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on February 27, 2026.

• Citation K0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on February 27, 2026.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on February 27, 2026.

• Citation E0032. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on February 27, 2026.

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CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 6, 2026.

  CMS has cited this home for F0656 2 times since 2023.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 21, 2025.

  CMS has cited this home for F0689 2 times since 2023.

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CMS fine of $8,278 on February 11, 2025.

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CMS stopped payment for new admissions from December 5, 2024, for 32 days.

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CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 6, 2025.

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CMS lists this as a standard inspection.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on December 18, 2024.

• Citation F0657. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on December 18, 2024.

• Citation F0726. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on December 18, 2024.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 18, 2024.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on December 18, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on December 18, 2024.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on December 18, 2024.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on December 18, 2024.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on December 18, 2024.

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CMS lists this as a standard inspection.

• Citation K0926. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

  CMS lists it as corrected on December 2, 2024.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on December 2, 2024.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on December 2, 2024.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0774. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Help the resident with transportation to and from laboratory services outside of the facility.

  CMS lists it as corrected on November 19, 2024.

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CMS lists this as a complaint inspection.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on October 31, 2024.

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CMS lists this as a complaint inspection.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on September 27, 2024.

• Citation F0790. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide routine and 24-hour emergency dental care for each resident.

  CMS lists it as corrected on September 27, 2024.

  CMS has cited this home for F0790 2 times since 2023.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on January 23, 2024.

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CMS lists this as a complaint inspection.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on November 8, 2023.

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CMS lists this as a standard inspection.

• Citation F0756. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on March 9, 2023.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on March 9, 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 9, 2023.

• Citation F0578. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 9, 2023.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on March 9, 2023.

• Citation F0759. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on March 9, 2023.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on March 9, 2023.

• Citation F0636. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on March 9, 2023.

• Citation F0639. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Maintain 15 months of resident assessments in the resident's active clinical record.

  CMS lists it as corrected on March 9, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on March 9, 2023.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on March 9, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 9, 2023.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on March 9, 2023.

• Citation F0790. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide routine and 24-hour emergency dental care for each resident.

  CMS lists it as corrected on March 9, 2023.

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CMS lists this as a standard inspection.

• Citation K0345. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on March 1, 2023.

• Citation K0781. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on March 1, 2023.

• Citation K0355. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on March 1, 2023.

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