Rosewood Rehab: Failed CPR for Full Code Resident TX
CONVERSE, TX - Federal inspectors found that Rosewood Rehabilitation and Care Center failed to initiate cardiopulmonary resuscitation for a resident designated as "full code" who was discovered without a pulse, leaving the individual without potentially life-saving intervention for over an hour before emergency medical services arrived.
Critical Delay in Emergency Response Procedures
The most serious violation documented during the July 27, 2024 inspection occurred when a nurse discovered an unresponsive resident at 10:02 PM but failed to immediately check the resident's code status or initiate CPR. According to the inspection report, the resident remained without pulse or respirations until Emergency Medical Services arrived at 11:23 PM - a critical 81-minute delay.
The resident was classified as "full code," meaning they had specifically requested all life-sustaining measures, including CPR, be performed in the event of cardiac or respiratory arrest. Despite this clear directive, nursing staff did not follow the facility's own emergency protocols.
The licensed vocational nurse involved in the incident was terminated following an investigation. The facility's medical director was notified at 12:02 PM the following day but provided no additional instructions regarding the incident response.
Understanding Code Status and Emergency Protocols
In healthcare settings, a patient's "code status" determines what level of medical intervention should be provided during life-threatening emergencies. Full code status means healthcare providers should perform all available resuscitation measures, including chest compressions, artificial ventilation, medications, and electrical cardioversion if necessary.
When a person experiences cardiac arrest, brain cells begin dying within 4-6 minutes due to lack of oxygen. Immediate CPR can double or triple a person's chance of survival by maintaining blood circulation and oxygen delivery to vital organs until advanced medical care arrives. The American Heart Association emphasizes that prompt recognition and immediate action are critical factors in successful resuscitation outcomes.
The failure to provide timely CPR represents a fundamental breach of established medical protocols. Current guidelines recommend that healthcare providers immediately assess responsiveness, check for breathing and pulse, and begin chest compressions within 10 seconds of recognizing cardiac arrest in patients with full code status.
Facility's Corrective Action and Staff Training
Following the incident, Rosewood Rehabilitation implemented comprehensive corrective measures. The Director of Nursing conducted mandatory training for all licensed nursing staff on July 29, 2024, covering resident code status verification, hospice care protocols, and emergency response procedures.
The training emphasized several key points: hospice residents can elect to remain full code, nurses must immediately check code status in the electronic medical record when finding unresponsive residents, and staff must initiate CPR while simultaneously calling for emergency assistance. A flow chart outlining proper response procedures was posted at nursing stations as a visual reminder.
The facility completed a 100% audit of all 59 residents' code status documentation, verifying that face sheet information matched physician orders. The audit revealed 31 residents with full code orders and 28 with do-not-resuscitate (DNR) orders. Of the 10 residents receiving hospice care, three maintained full code status.
Post-training assessments confirmed that all nursing staff could correctly identify where to locate code status information, understand hospice patients' rights to remain full code, and demonstrate knowledge of appropriate emergency responses.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Avir at Converse in CONVERSE, TX was cited for violations during a health inspection on July 27, 2024.
Despite this clear directive, nursing staff did not follow the facility's own emergency protocols.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.