Rosewood Post Acute
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an
interview on 7/31/25 at 9:31 a.m., with Resident 1's family member (RFM) 1, RFM 1 stated Resident 1 told her that LVN 1 hit Resident 1 in his right leg when LVN 1 told the resident to scoot back to his bed. RFM 1 stated she spoke to LVN 1 about the incident and LVN 1 denied the allegation. RFM 1 stated she could not remember the date of the incident.Review of Resident 1's departmental notes did not indicate an incident when resident accused LVN 1 of hitting his right leg.During a review of Resident 1's admission Record, dated 7/31/25, indicated, Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses that included muscle weakness.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 5/18/25 under Section C, it indicated a score of 13, meaning Resident 1 was cognitively intact. During an
interview on 8/4/25 at 5:15 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she remembered an incident when Resident 1 accused LVN 1 of hitting his right leg when she was trying to assist the resident to get back to his bed. LVN 1 further stated that RFM 1 called the facility on the phone and asked LVN 1 if
she hit Resident 1's leg. LVN 1 stated she denied the allegation, but she did not report the alleged abuse incident to her supervisor. LVN 1 stated she should have reported the incident to her supervisor and the Administrator per facility's abuse policy so the incident would have been investigated. LVN further stated that there were no other staff that knew of the incident, and she could not remember the date when the incident happened.During an interview on 8/6/25, at 12:30 p.m., with the Administrator (Adm), stated LVN 1 should have reported the alleged abuse incident to the Adm.During a review of the facility's undated policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, the P&P indicated, . 7.3 Report allegations involving neglect, exploitation or mistreatment (including injuries or unknown source) . within 24 hours if the event does not result in serious bodily injury. 7.4 notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards .7.6 Initiate an investigation within 2 hours of an allegation of abuse.7.7 The investigation will be thoroughly documented.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Rosewood Post Acute in PLEASANT HILL, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PLEASANT HILL, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Rosewood Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.