Rosenberg Health & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents (Resident #2) reviewed for pressure ulcers. The facility failed to complete wound assessments for Resident #2's left heel wound that developed in the facility for approximately 5 weeks. This failure placed the resident at risk for infection, impaired healing, further skin breakdown, and delayed identification of changes in wound status.

Inspectors wroteBased on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents (Resident #1) reviewed for PASARR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days following Resident #1's Interdisciplinary Team meeting. This failure placed residents at risk for inadequate care, and losing access to specialized mental health or intellectual disability services.

Inspectors wroteACRONYMS:BIMS: Brief Interview of Mental StatusRN: Registered NurseDON: Director of NursingADON: Assistant Director of NursingMDS: Minimum Data SetADM: AdministratorBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment to ensure that resident's care plan was reviewed and revised by the interdisciplinary team to address 1 of 4 residents (Resident # 1's) allegation. The facility failed to ensure that Resident # 1's care plan was revised to address her sexual allegation This failure could place 94 residents at risk of being sexually abused. Record review of Resident # 1's admission face sheet dated 01/08/2026, retrieved on 01/28/2026 at 10:17 a.m., revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. Her diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment for 1 of 5 residents (CR #1) reviewed for quality of care in that: CR #1 had a palm protector medical device on his contracted left hand for approximately 7 days, resulting in admission to an acute care hospital on [DATE] with left hand pain, cellulitis, and deep, open pressure wound that involved the thenar web space (the space between the index finger and thumb) that appeared chronic with a foul odor. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 11/11/25 and ended on 11/18/25. The facility corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents as was possible for 1 (Resident #1) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure a system was in place to adequately supervise Resident #1 when he left the faciity on [DATE] and did not return. The facility failed to notify law enforcement or conduct a thorough search for Resident #1. As of 03/21/25, the facility did not know Resident #1's whereabouts. An immediate Jeopardy (IJ) was identified on 03/21/25. The IJ Template was provided to the facility on [DATE] at 2:09 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, encompassing the resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders for 1 of 12 residents (Resident #1) reviewed for behavioral services. The facility failed to ensure Resident #1 received adequate behavioral health care services to prevent and treat substance abuse disorder when Resident #1 frequently signed himself out of the facility to go to nearby stores and consume alcohol, resulting in intoxication, vomiting, and lethargy to the point of falling out of his wheelchair. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen. -Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. -Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen. This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. The facility failed to ensure 2 of 2 dumpster lids were secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #27) reviewed for pharmacy services. The facility failed to acquire and administer Resident #27's scheduled dose of Clonazepam for several days. This failure could place residents at risk of decreased therapeutic efficiency and a poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances for 1 of 3 (Resident#1) residents reviewed for grievances. -The facility failed to establish a grievance policy that includes the right to obtain a written decision regarding a resident's grievance. -The facility did not provide a written decision to Resident #1 who filed grievances. These failures could place residents at risk for feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents hazards and supervision, in that: The facility failed to ensure Resident #1's noodles were served at the appropriate temperature, which resulted in a burn to the palm of her hand. The failure could place residents at risk of experiencing accidents, injuries, and/or death. Findings Included : Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #2) of 5 residents reviewed, in that: [NAME] A denied Resident #2, the 2 cheese flour tortillas requested on his breakfast meal ticket every morning. This failure could place residents at risk for decreased quality of life and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 (DA A) kitchen staff reviewed for dietary services . During lunch, DA A failed to wear gloves and properly clean his hands during service while he touched his face mask, key chain, and rubbed his eyes. This failure could place residents at risk for injury and food borne illness during food preparation and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #1) reviewed for incontinent care. -The facility failed to ensure CNA J properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 2 residents (Resident #1) reviewed for infection control. -The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care for 2 of 3 residents (CR # 1 and #2) reviewed for an effective discharge process. -CR#1 was discharged on 05/17/2024 and a discharge summary was not completed. -CR#2 was discharged on 06/04/2024 and a discharge summary was not completed. These failures could affect residents who are discharged from the facility by not providing a recapitulation of the residents stay and a final summary of the residents' status for any continuation of care that may be required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's environment remained as free as possible of accident hazards and each resident received adequate supervision to prevent accident for 1 (CR #1) of 4 residents reviewed for adequate supervision. The facility failed to provide adequate supervision and training of the staff when they incorrectly used Hoyer lift while transferring CR#1 from a shower chair to her bed on 05/02/2024. This failure placed residents living in the facility at risk of harm due to avoidable accidents by staff not properly using equipment when transferring residents from shower chair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed colostomy (stool or urine collection pouch that is attached to the skin) care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (CR #1, R #2) of seven residents reviewed for colostomies and catheter care. The facility failed to: -Ensure CR #1 and R #2's catheter was emptied per shift as ordered by physician. -This failure placed residents with a colostomy at risk of in delay in treatment/care, infection, discomfort, decreased quality of care. Findings Included: Record review of CR #1's undated face sheet revealed a [AGE] year-old who male who was initially admitted to the facility on [DATE] and re-admitted on [DATE] and discharged [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 25 of 30 residents (Resident #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, #75, #20, #7, #44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and #38) reviewed for infection control. The facility failed to ensure that Residents (#44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and 38) who received negative COVID test results were not accommodated in a shared room alongside Residents(Resident #92, #78, #9, #77, #73, #39, #71, #74, #75, #20 and #7) who had tested positive for COVID 19 and were identified as droplet isolation precaution Residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and safety. The facility did not provide soap for staff to wash their hands at the hand washing sink in the kitchen. This failure cold place all residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for 1 of 13 resident rooms reviewed for homelike environment. 1. The facility failed to clean the floor and wall in Resident #29's room. 2. The facility failed to provide clean linens for Resident #29's bed. These failures could affect all residents by decreasing their sense of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 (Resident #203) of 4 residents reviewed for baseline care plans. Resident #203 was admitted on [DATE] but the facility failed to ensure her baseline care plan was initiated until 12/29/23. This failure could result in newly admitted residents not receiving person-centered care in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (CR #1) of four residents reviewed for medication administration. -The facility failed to ensure CR #1 received medications as ordered by the physician. The failure could place residents at risk of medicinal adverse effects, decreased health status and being hospitalized .

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and timeframes to meet residents' physical, mental and psychosocial needs for 1 of 10 residents (CR#1) reviewed for care plans. The facility failed to implement CR #1's care plan, which included 1:1 monitoring for a history of diet noncompliance, to ensure he ate nothing by mouth. On 12/1/23, CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on 12/6/2023 at 2:55 p.m. While the IJ was removed on 12/8/2023 at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision to ensure CR#1 ate nothing by mouth when he had a Gastrostomy tube (G-tube) for enteral feedings due to dysphagia and history of aspiration/choking. On 12/1/23, CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on 12/6/2023 at 2:55 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 1 resident (CR #1) reviewed for safe discharge. -The facility failed to provide sufficient preparation to ensure safe and orderly discharge of CR #1. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control, in that: -Wound Care Nurse failed to perform hand hygiene when moving from a dirty to clean while performing Resident #1's wound care. This failure could place residents at risk for infections.

Inspectors wroteBased on interview and record review, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR#1) of 9 residents reviewed for professional standards. The facility failed to follow physician orders postponing the resident's procedure on two occasions. This failure could place residents at risk of inadequate care, decline in their health and or hospitalization.