Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosenberg Health & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact female resident with bipolar disorder, mild cognitive impairment, major depressive disorder, and anxiety, who was receiving psychotropic medications, made an allegation of sexual abuse by a staff member. Her existing care plan addressed monitoring for psychotropic side effects but was never revised to include or address the sexual abuse allegation. Multiple staff members, including RNs, the MDS Coordinator, ADON, DON, and the ADM, acknowledged that care plan development and updates were their responsibility and confirmed that the care plan had not been updated after the incident, without being able to explain why, despite a facility abuse policy that prohibits sexual abuse and requires oversight and staff education.
A resident with severe cognitive impairment and contractures had a palm protector device placed on his hand without a physician's order or proper monitoring. Staff failed to remove the device to assess skin integrity, resulting in a deep, foul-smelling wound and cellulitis that required hospital admission. Lack of documentation, communication, and staff training contributed to the deficiency.
A resident with multiple medical conditions and intact cognition left the facility without signing out or notifying staff of his destination or expected return. Staff failed to follow established policies for therapeutic leave, did not ensure the resident had his medications, and did not attempt to contact him or notify law enforcement when he did not return. The facility was unable to account for the resident's whereabouts for several days, resulting in a deficiency related to inadequate supervision and accident prevention.
The facility's kitchen failed to label and date thirteen 8 oz glasses of juice and nine 4 oz glasses of applesauce, as observed during a survey. Interviews with the Dietary Manager and other staff highlighted the importance of labeling and dating to prevent foodborne illnesses and allergic reactions. The facility's Nutrition Policies and Procedures require proper labeling with an expiration or use-by date.
The facility failed to secure the lids of two dumpsters, leaving garbage exposed and potentially attracting rodents. Interviews with the Nutrition Director and other staff confirmed that the responsibility for closing the dumpster lids lay with the dietary and kitchen staff. This failure to adhere to the facility's policies on garbage disposal could pose a health risk to residents.
A facility failed to administer Clonazepam to a resident with anxiety due to a lack of prescription, despite the medication being available in the e-kit. Staff attempted to contact the physician and pharmacy, but the medication was not dispensed until several days later. The resident, with a history of schizophrenia and other conditions, did not exhibit increased inappropriate behavior, but the failure could have impacted therapeutic efficiency.
A facility failed to provide written decisions for grievances filed by a resident, despite multiple requests. The resident, who was cognitively intact, filed grievances regarding patient care and medication administration but was only verbally informed of the resolutions. The facility's policy did not include the provision of written grievance decisions, and staff confirmed this practice during interviews.
A resident with a history of epilepsy and dementia suffered a burn to her hand after being handed a cup of hot noodles without a tray, despite her known tendency to shake. The dietary aide, who was not responsible for checking food temperatures, failed to follow the facility's protocol for handling hot food, leading to the incident.
A resident with Parkinson's Disease and other health issues was not receiving the requested cheese flour tortillas for breakfast, as specified on his meal ticket. Despite being cognitively intact and having clear dietary instructions, the resident consistently received toast instead. The dietary staff, particularly one member, failed to follow the meal ticket instructions, leading to disciplinary action.
A kitchen staff member failed to wear gloves and maintain proper hand hygiene during food service, touching various unclean surfaces and continuing to handle food trays. The facility's dietary manager acknowledged the risk of cross-contamination, especially with COVID-19 present, and the facility's policy requires minimizing bare hand contact with ready-to-eat food.
A resident with severe cognitive impairment and incontinence did not receive proper incontinent care, as a CNA failed to clean the urinary meatus thoroughly. The facility's peri-care guidelines were not followed, potentially risking infections. The DON confirmed expectations for complete care and noted training was provided, but no peri-care policy was available at survey exit.
A CNA in an LTC facility failed to perform proper hand hygiene during incontinence care for a resident with Alzheimer's and other conditions, leading to potential cross-contamination. The resident was dependent on staff for personal hygiene, and the CNA did not follow the facility's infection control policies, as confirmed by interviews with staff.
The facility failed to provide necessary discharge summaries and planning for two residents, one with cerebral and vascular conditions and another with heart and kidney issues. Both residents were discharged without the required documentation, which is crucial for their transition to post-discharge care. Staff interviews revealed that the expected discharge processes were not followed, leading to deficiencies in the facility's discharge planning.
A resident with multiple health conditions was injured during a transfer using a Hoyer lift due to inadequate supervision and possible mishandling by staff. Despite the equipment being in good working order, the resident fell and sustained a laceration. The facility's mechanical lift policy was not properly followed, leading to this incident.
The facility failed to provide proper catheter care for two residents, leading to potential risks of infection and discomfort. One resident with paraplegia and a colostomy had a full catheter bag and a urinary tract infection, while another resident with Parkinson's disease experienced neglect in catheter care. Staff inconsistencies and workload issues contributed to the deficiencies.
The facility failed to maintain an infection control program, leading to the mixing of COVID-positive and COVID-negative residents in shared rooms, inadequate PPE provision, and improper hand hygiene by staff. Misadvised by the Regional Nurse, the facility's actions resulted in the spread of COVID-19 among residents.
The facility failed to maintain a sanitary and comfortable environment for a resident, as observed with unclean floors, stained walls, and soiled bed linens. The resident confirmed the room was only cleaned after state surveyors arrived, and the housekeeper noted staffing shortages due to COVID.
Failure to Revise Care Plan After Resident’s Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive care plan to address a resident’s allegation of sexual abuse. The resident was an adult female with bipolar disorder, mild cognitive impairment, major depressive disorder, and anxiety, who was cognitively intact with a BIMS score of 15 and had no hallucinations or delusions documented on her MDS. Her care plan, initiated for psychotropic medication use related to depression and anxiety, included monitoring for side effects such as mania, hostility, rage, impulsive behavior, and hallucinations, with a goal for her to be free from cognitive/behavior impairment. However, after the resident made an allegation of sexual abuse by a staff member, the care plan was not updated to reflect this allegation or to address it as part of her individualized plan of care. Interviews with multiple staff confirmed that the care plan was not revised following the sexual abuse allegation. RN B stated she did not know why the care plan was not updated and indicated that the MDS Coordinator and management staff were responsible for care plans, while nurses implemented them. The MDS Coordinator acknowledged awareness of the sexual abuse incident and, after reviewing the resident’s care plan from late September through late January, confirmed it had not been updated to include the allegation and could not explain why. The ADON, DON, and Administrator each stated that management or the MDS Coordinator was responsible for developing and updating care plans and acknowledged that the resident’s care plan had not been updated, without being able to provide a reason. Facility policy on abuse required protection of residents’ health, welfare, and rights, prohibited sexual abuse, and required oversight and staff education to prevent abuse, but the care plan remained unchanged despite the reported allegation.
Failure to Monitor and Document Palm Protector Use Leads to Severe Hand Injury
Penalty
Summary
A resident with severe cognitive impairment, hemiplegia, and multiple comorbidities was admitted to the facility and was dependent on staff for all activities of daily living. The resident had a history of contractures and was at risk for skin breakdown, as documented in his care plan. Despite these risks, a palm protector device was placed on his contracted left hand without a physician's order, care plan update, or proper monitoring. The device remained on the resident's hand for approximately seven days, during which time staff failed to remove the device to assess the underlying skin integrity, as required by professional standards and facility policy. Multiple staff members, including nurses and CNAs, observed the device on the resident's hand but did not remove it or adequately assess the skin beneath. Some staff were unaware of who placed the device or the need for monitoring, and there was no documentation of the device in the resident's treatment record. The therapy department did not recommend the device, and the occupational therapist could not find any documentation supporting its use for this resident. Nursing staff performed routine skin assessments but did not remove the device, and changes in the resident's hand condition, such as swelling, redness, and the presence of a wound, were either not noticed or not reported in a timely manner. The deficiency became evident when the resident was observed with a swollen, red, and painful left hand, with a deep, foul-smelling wound in the thenar web space. The device was found embedded in the wound, and the resident was subsequently transferred to an acute care hospital, where he was diagnosed with cellulitis, leukocytosis, and a deep, chronic-appearing pressure wound. Interviews with staff revealed a lack of training and awareness regarding the use and monitoring of assistive devices, as well as failures in communication and documentation. The facility's failure to ensure proper assessment, monitoring, and documentation of the palm protector device directly led to the resident developing a serious, avoidable injury.
Removal Plan
- Audit all residents with palm protectors and splints to ensure orders and care plans are in place
- Educate staff
- Conduct skin sweep
- Monitor hand roll/splint placement, removal, and skin integrity
- Train therapy department on donning and doffing of braces, splints, and palm guards
- Train nursing and therapy staff on assistive devices, including obtaining doctor's orders prior to placement, notifying nursing department of order and device placement, and monitoring as indicated
- Train nursing staff, including CNAs, nurses, and medication aides, on notification of changes of condition, including any change to a resident's skin, and reporting the change of condition to the nurse
- Educate Treatment Nurse A on skin assessments and removing assistive devices to assess skin integrity
- Implement orders, care plans, and monitoring on treatment record for residents utilizing palm protectors and splints
- Assess all residents' skin for suspicious areas or marks
- Complete skin assessments for all residents
- Train therapy and nursing staff on assistive device procedures, including obtaining an order, following the order including time restrictions for the device, and monitoring the use of the device
Failure to Supervise and Account for Resident on Therapeutic Leave
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistance devices to prevent accidents for a resident who left the facility and did not return. The resident, a male with diagnoses including candidiasis, cellulitis, depression, cognitive communication deficit, and unsteadiness on his feet, was assessed as having intact cognition with a BIMS score of 13 and was independent in most self-care activities. Despite this, the resident was not care planned for leaving on pass, and his Elopement/Wandering Risk Assessment indicated a low risk with no plan of care needed. On the day of the incident, the resident left the facility without signing out, and staff did not know his whereabouts or whether he had taken his medications with him. Multiple staff interviews revealed a lack of clarity and communication regarding the resident's departure. The nurse on duty was informed by another nurse that the resident had gone out on pass but did not see him during her shift and noted his absence in the progress notes. The DON and ADONs were aware the resident had left but did not know where he was or when he was expected to return. The receptionist allowed the resident to go outside, believing he intended to sit on the porch, and later realized he had left the premises and entered a vehicle. The staff did not ensure the resident signed out or provided information about his destination or expected return, as required by facility policy. The facility's policies required residents or their representatives to sign a release form with details of their leave and for staff to attempt contact if a resident did not return as expected. However, these procedures were not followed, and there was no immediate notification to law enforcement or a thorough search conducted when the resident did not return. The lack of adherence to established protocols and insufficient supervision placed the resident at risk, and the facility was unable to account for his whereabouts for several days.
Removal Plan
- DON/designee located and visited Resident #1 at the Personal Care Home in a nearby city.
- Resident #1 had a safe discharge to the Personal Care Home with the assistance of the Personal Care Home manager and the Administrator delivered all medications. DON evaluated resident #1 at the Personal Care Home to ensure his safety and well-being.
- Administrator and DON were in-serviced by Regional Nurse Consultant on the Missing Resident Policy, along with notifying the police/RP/physician and the state agency when resident is not located in the facility or on facility grounds.
- Don/designee will have the 1:1 training with the receptionist on Therapeutic Leave policy and to notify charge nurse of residents that have not returned from leave that day when the receptionist shift is over and the Missing Resident Policy.
- Residents therapeutic leave sign out book will be located at receptionist desk for her/him to know who is leaving. The Charge nurses will be responsible for tracking of the residents leaving after 5:30pm.
- Don/designee will educate charge nurses on giving a follow-up call to resident/RP that did not return from therapeutic leave for the day and document in progress notes. Any charge nurse not present will not be allowed to work their next shift until receiving the education.
- DON/designee will have 100% of resident's Elopement Risk Assessment completed to identify all elopement risk residents.
- DON/designee will identify all the residents with the physical ability to have therapeutic leave.
- DON/designee will In-service all staff on the Missing Person Policy. Any staff not present will not be allowed to work their next shift until they have the training.
- DON/designee will In-service all staff on the Therapeutic Leave Policy. Any staff not present will not be allowed to work their next shift until they have the training.
- Missing Person Drill will be completed and documented with all staff. Any staff not present will not be allowed to work their next shift until they have the drill.
- The Elopement binder will be updated with any newly identified residents.
- All the residents identified as Elopement Risk will have their care plans updated by DON/designee.
- All residents identified with physical ability for Therapeutic Leave will have their care plan updated by DON/designee.
- DON/designee will educate residents/responsible party on the Therapeutic Leave Policy for those residents identified with the physical ability for therapeutic leave.
- Administrator will have an ad hoc meeting with the Medical Director on IJ findings and actions taken.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the kitchen, as observed during a survey. Specifically, thirteen 8 oz glasses of juice and nine 4 oz glasses of applesauce were found in the facility refrigerator without labels or dates. This oversight was confirmed through interviews with the Dietary Manager, who acknowledged the importance of labeling and dating food items to prevent foodborne illnesses and allergic reactions. Additional interviews with other staff members corroborated the necessity of labeling and dating to ensure food safety, as they expressed concerns about the potential risks of using unlabeled and undated food items. The facility's Nutrition Policies and Procedures, dated December 5, 2017, also emphasize the requirement for proper labeling with an expiration or use-by date.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the lids of two dumpsters were secured. During an observation, it was noted that both Dumpster #1 and Dumpster #2 had their lids completely open, exposing the garbage. Interviews with the facility's Nutrition Director, a staff member, and a Tray-Aide confirmed that the responsibility for keeping the dumpster lids closed fell on the dietary and kitchen staff. The Nutrition Director, who had been with the facility for seven years, acknowledged the risk of potential rodent infestation and subsequent health risks to residents if the dumpster lids were left open. The facility's policies, including the Nutrition Policies and Procedures and the Food-Related Garbage and Rubbish Disposal policy, clearly stated that dumpsters must be covered with lids and kept closed when not in use. These policies were not adhered to, as evidenced by the open dumpster lids. The failure to secure the dumpster lids could lead to exposure to germs and diseases carried by rodents, posing a risk of infection to the residents. The staff interviews highlighted a lack of adherence to these policies, which could potentially compromise the health and safety of the residents.
Failure to Administer Clonazepam as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in acquiring and administering the scheduled dose of Clonazepam for several days. The resident, a male with a history of respiratory failure, cerebral infarction, depression, and schizophrenia, was admitted with a prescription for Clonazepam to manage anxiety. However, the medication was not administered on multiple occasions due to it being on hold, as there was no prescription available. The nursing staff, including a Medication Aide (MA) and a Licensed Vocational Nurse (LVN), were aware of the missing medication and attempted to contact the physician and pharmacy to resolve the issue. Despite these efforts, the medication was not dispensed until several days later. The facility had an emergency kit (e-kit) that contained Clonazepam, but the staff did not utilize it due to the lack of a triplicate prescription from the doctor, which was necessary to access the medication from the e-kit. Interviews with various staff members, including the Assistant Director of Nursing (ADON) and the interim Director of Nursing (DON), revealed that there was a lack of consistent action in obtaining the medication from the e-kit. The consulting pharmacist confirmed that the medication was available in the e-kit but was not dispensed until a script was received. The resident's behavior was monitored, and while there were no increased episodes of inappropriate behavior, the failure to administer the medication as ordered could have led to decreased therapeutic efficiency and a poor quality of life for the resident.
Failure to Provide Written Grievance Resolutions
Penalty
Summary
The facility failed to establish a grievance policy that ensures the prompt resolution of grievances, specifically by not providing written decisions to residents. This deficiency was identified during a survey where it was found that the facility's grievance policy did not include the right for residents to obtain a written decision regarding their grievances. The policy only mentioned verbal communication of grievance resolutions, which was confirmed by the facility's staff during interviews. A resident, who was cognitively intact with a BIMS score of 15, filed grievances related to patient care and medication administration. Despite multiple requests, the resident did not receive written documentation of the grievance resolutions. The facility's Administrator and Social Worker confirmed that it was the company's policy not to provide written documentation, considering the grievance form an internal document not accessible to residents or surveyors. Interviews with facility staff, including the Administrator, Social Worker, and Interim DON, revealed a consistent practice of not providing written grievance resolutions. The staff acknowledged that this practice could lead to residents feeling that their grievances were not resolved. The facility's grievance policy, last revised in 2023, did not address the provision of written decisions, contributing to the deficiency identified by the surveyors.
Resident Burned Due to Improper Handling of Hot Food
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and provided adequate supervision to prevent accidents. This deficiency was evident in the case of a resident who suffered a burn to the palm of her hand due to improper handling of hot food. The resident, who had a history of epilepsy, unsteadiness on feet, seizures, and dementia, required supervision and assistance during meals. Despite this, the resident was allowed to handle a cup of hot noodles without appropriate support, leading to the burn incident. The incident occurred when the resident requested her cup of ramen noodles to be warmed in the microwave. A dietary aide, who was not a cook and typically did not handle food temperatures, warmed the noodles and handed them directly to the resident without using a tray, despite knowing the resident had a tendency to shake. This action resulted in the hot liquid spilling and burning the resident's hand. The dietary aide admitted to not thinking about the resident's condition at the time of the handoff. Interviews with staff and the resident confirmed that the noodles were handed over without the usual precaution of using a tray, which was a deviation from the facility's protocol. The facility's food safety policy required that food be handled with care, especially when hot, and that bare hand contact with ready-to-eat food be minimized. The failure to adhere to these protocols contributed to the resident's injury.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodates the preferences of a resident, specifically Resident #2, who was not receiving the two cheese flour tortillas requested on his breakfast meal ticket every morning. Despite the resident's cognitive intactness and clear dietary instructions for large portions, the resident reported consistently receiving two slices of toast instead of the requested tortillas. The resident expressed frustration over this issue, which he felt was being done intentionally. Interviews revealed that the dietary staff, particularly [NAME] A, did not follow the meal ticket instructions, despite being aware of the resident's request. [NAME] A admitted to not providing the tortillas and acknowledged the oversight, although she claimed the order was not read out to her. The Dietary Manager (DM A) confirmed that the meal tickets clearly highlighted the extra requests and that the dietary staff were instructed to follow them. The facility's administration was aware of the issue, as the resident had reported it, but the problem persisted, leading to disciplinary action against [NAME] A for not adhering to the meal ticket instructions.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a lunch service. A kitchen staff member, identified as DA A, did not wear gloves and failed to maintain proper hand hygiene while handling food. During the service, DA A was seen touching his face mask, key chain, and rubbing his eyes without washing his hands afterward. He also used his shirt to wipe his eyes, exposing his bare back and boxers, and continued to handle food trays without washing his hands or wearing gloves. DA A admitted to not wearing gloves since his employment began eight months prior and was unaware of the requirement, indicating a lack of enforcement of sanitary practices. The facility's dietary manager, DM A, was informed of the unsanitary practices and acknowledged the potential for cross-contamination, especially with the presence of COVID-19 in the facility. The facility's Food and Safety sanitation policy requires thorough hand washing after touching the face or hair and mandates minimizing bare hand contact with ready-to-eat food. The policy also specifies the use of suitable utensils or single-use gloves to prevent contamination. The failure to follow these guidelines could place residents at risk for foodborne illness during food preparation and service.
Inadequate Incontinent Care Leading to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, a female with Alzheimer's disease, cognitive communication deficit, and bipolar disorder, was admitted to the facility with severe cognitive impairment and was always incontinent of both bowel and bladder. The care plan indicated that the resident was dependent on staff for toileting and personal hygiene. During an observation, a CNA did not properly clean the resident during incontinent care, specifically failing to spread the resident's labia to clean the urinary meatus thoroughly. The CNA admitted to not performing the necessary cleaning steps because she had changed the resident's diaper earlier in the day. The Director of Nursing stated that staff were expected to provide complete and proper incontinent care each time it was performed, and that training and competency checks were provided upon hire and quarterly. However, no policy on peri care was provided at the time of the survey exit. The facility's Nursing Peri-Care Performance Criteria outlined specific steps for cleaning, which were not followed by the CNA, potentially placing the resident at risk for infections.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a certified nursing assistant (CNA) during the provision of incontinence care to a resident. The CNA did not perform hand hygiene before entering the resident's room or before donning clean gloves. During the care, the CNA failed to properly clean the resident and did not change gloves appropriately, leading to potential cross-contamination. The resident involved was an elderly female with Alzheimer's disease, cognitive communication deficit, and bipolar disorder. She was severely cognitively impaired and dependent on staff for activities of daily living, including toileting and personal hygiene. The resident's care plan indicated she required total assistance for these tasks, highlighting the importance of proper infection control practices during care. Interviews with facility staff, including the CNA, the Wound Care Nurse, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed the failure in hand hygiene practices. The CNA admitted to not recalling competency checks for incontinence care and acknowledged the risk of cross-contamination. The facility's infection preventionist and DON emphasized the importance of hand hygiene, as outlined in the facility's policies, which were not adhered to during the incident.
Deficient Discharge Planning and Documentation
Penalty
Summary
The facility failed to develop and implement an effective discharge process for two residents, leading to deficiencies in providing necessary discharge summaries and planning. For the first resident, a female with a history of cerebral infarction, cerebral edema, and moyamoya disease, there was no evidence of discharge planning or a completed discharge summary upon her discharge. The resident's care plan indicated a need for assistance with activities of daily living, but the discharge summary, which should have been completed within 24 to 72 hours, was missing. Interviews with facility staff revealed that the discharge summary was not initiated or completed as expected. The second resident, a male with heart failure, acute kidney failure, and bipolar disorder, also lacked a discharge summary and planning documentation. This resident was involved in an incident where he was found smoking marijuana and possessing a firearm, leading to his removal by law enforcement. Despite the unplanned nature of his discharge, the facility's policy required a discharge summary to be completed, which was not done. Staff interviews indicated that the interdisciplinary discharge summaries were expected to be completed and sent with the resident at discharge, but this did not occur. The facility's discharge planning policy, dated 2016, mandates a post-discharge plan of care developed with the resident's participation, indicating the resident's future living arrangements and follow-up care. However, this policy was not adhered to for the two residents in question, as evidenced by the lack of discharge summaries and planning. The absence of these critical documents could affect the residents' transition to post-discharge care, as they do not provide a recapitulation of the residents' stay or a final summary of their status for any required continuation of care.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to an accident during a transfer using a Hoyer lift. The incident involved a female resident with a history of cerebral infarction with aphasia, contracture, cognitive communication deficit, and Type 2 Diabetes Mellitus. The resident required two-person assistance for transfers, as outlined in her care plan. On the day of the incident, two CNAs were transferring the resident from a shower chair to her bed using a Hoyer lift when the resident slipped out and fell, sustaining a laceration to her right upper eye. The investigation revealed that the Hoyer lift and sling were in good working order, with no malfunctions or visible damage. Statements from the CNAs involved indicated that the lift's legs were wide open, and the straps were secure during the transfer. However, the resident began moving, and despite attempts to stabilize her, she fell. Other staff members interviewed stated that the resident should not have fallen if the equipment was used correctly, suggesting a possible error in securing the sling or handling the lift. The facility's mechanical lift policy outlines specific procedures for using the Hoyer lift, including verifying physician orders, securing the sling properly, and ensuring the resident's safety during transfers. Despite these guidelines, the incident occurred, indicating a lapse in following established protocols. The facility's grievance log showed no prior concerns regarding Hoyer transfers for this resident, and subsequent observations of Hoyer lift transfers were conducted without issues.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper catheter care for two residents, leading to potential risks of infection and discomfort. One resident, a 44-year-old male with paraplegia and a colostomy, had a physician's order for urinary catheter care every shift. However, records and interviews revealed that his catheter bag was often left full, leading to a urinary tract infection. The resident reported that staff did not assist him adequately, and his call light was taken away, preventing him from requesting help. EMS records confirmed that his catheter bag contained over 2000ml of urine at the time of hospital admission, and hospital records noted a foul odor in his urine and positive urine cultures for infection. Another resident, an elderly male with Parkinson's disease and neurogenic bladder, also experienced neglect in catheter care. His physician's orders required catheter care every shift, but observations and interviews indicated that his catheter bag was frequently left full. The resident reported that the night shift staff rarely emptied his bag, and he could not recall the last time it was changed. During a facility round, his catheter bag was observed to be full, and the attending LVN confirmed that it should have been emptied to prevent infection. Interviews with staff, including CNAs and LVNs, revealed inconsistencies in catheter care practices. Some staff members stated that the residents were responsible for emptying their own bags, while others admitted to neglecting the task due to workload or the residents' refusal to cooperate. The Director of Nursing acknowledged that full catheter bags were unacceptable and emphasized the need for constant monitoring. The facility's policy on indwelling catheter care, which mandates routine changes and monitoring to prevent infections, was not adhered to, leading to the identified deficiencies.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 25 of 30 residents reviewed for infection control. The facility did not ensure that residents who received negative COVID test results were not accommodated in a shared room alongside residents who had tested positive for COVID-19 and were identified as droplet isolation precaution residents. Additionally, the facility failed to ensure transmission-based precaution protocols, evidenced by the inadequate placement of notices and insufficient provision of Personal Protective Equipment (PPE) in the vicinity of residents' rooms or within their immediate proximity. The facility also failed to ensure that staff implemented appropriate use of PPE and transmission-based precautions prior to entering and exiting residents' rooms. Staff members were observed entering droplet precaution rooms without the appropriate PPE and neglecting to wash or sanitize their hands after providing care to residents. This included instances where staff provided incontinent care and interacted with clean linen carts without prior hand hygiene, thereby increasing the risk of infection transmission. Interviews with staff and administration revealed a lack of proper training and understanding of infection control protocols. The DON and Administrator were misadvised by the Regional Nurse to keep positive COVID-19 residents in cohort rooms with negative residents, contrary to the facility's policy. This misinterpretation led to the spread of COVID-19 within the facility. Additionally, the facility failed to provide proof of in-services and staff training for infection control and transmission-based precautions, further exacerbating the issue.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for Resident #29. During an observation, the floor in Resident #29's room was found to have candy wrappers, food crumbs, droplets of a dried brown substance, and a jacket. The wall behind the resident's bed had about seven round yellowish-brown stains, and there was a dried red substance on the resident's sheets. The resident confirmed that the room was only cleaned after the state surveyors arrived and mentioned that the yellowish-brown substance on the wall was hot sauce, which housekeeping staff did not attempt to clean. The housekeeper interviewed stated that each employee was assigned a hall and that all rooms were cleaned once a day. She mentioned that cleaning staff were not supposed to touch personal items and that CNAs were responsible for changing soiled bed linens. The housekeeper also noted that Resident #29 would get upset if staff touched his personal belongings. She indicated that housekeeping had been short-staffed due to COVID. A request for the housekeeping policy was made but was not received.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 287 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rosenberg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cambridge Health And Rehabilitation Center | 2 mi | ★★★★★ | 8 | 0 |
| Oak Bend Medical Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Fort Bend Healthcare Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Paradigm At The Brazos | 2.3 mi | ★★★★★ | 0 | 0 |
| Richmond Health Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
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