Rosenberg Health & Rehabilitation Center
Rosenberg Health & Rehabilitation Center in Rosenberg, TX — inspection on November 20, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
11/18/25 revealed an area of concern of the assistive device system, including a resident with a palm protector without an order, palm protector placed on resident without nursing notification, and resident did not have palm protector routinely removed to assess skin integrity.
Interventions included an audit of all residents with palm protectors and splints to ensure orders and care plans were in place, staff education, skin sweep, hand roll/splint placement, removal and skin integrity monitoring.
Record review of an In-Service document (undated) revealed the therapy department was trained on donning (put on) and doffing (take off) of braces, splints, and palm guards.
Record review of an In-Service Training Report dated 11/18/25 revealed nursing and therapy staff were trained on assistive devices, including doctor's orders prior to placement, notification of order and device placement to nursing department and therapy/nursing monitoring as indicated.
Record review of an In-Service Training Report dated 11/18/25 revealed nursing staff, including CNAs, nurses and medication aides were trained on notification of changes of condition, including any change to a resident's skin, and reporting the change of condition to the nurse.
Record review of an In-Service Training Report dated 11/19/25 revealed the DON educated Treatment Nurse A on skin assessments and removing assistive devices to assess skin integrity.
Record review of the facility audit of residents utilizing palm protectors and splints (undated) revealed 7 residents had orders implemented, care plans implemented, and monitoring initiated on their treatment record. In observations on 11/20/25 between 10:46am and 6:55pm, Residents #1, #2 and #3 were not wearing palm protectors or splints. In an interview on 11/19/25 at 5:05pm, the DON said they completed an audit for all braces and therapy devices. He said they added orders and updated the residents' care plans. He confirmed they started training staff last night and trained every shift since then.
Record review of Weekly Shower/Bath Skin Check Sheets dated 11/18/25 revealed all residents had their skin assessed for suspicious areas or marks. In an interview on 11/20/25 at 3:37pm, the ADON confirmed the facility completed skin assessments for all residents on 11/18/25. In interviews on 11/20/25 between 11:15am and 536pm with CNA C, CNA D and CNA E, they stated they received training on changes in condition and would report any changes to a residents' skin integrity to the nurse. In interviews on 11/20/25 between 2:22pm and 6:15pm, the Therapy Manager, COTA A, COTA B, ADON, DON, LVN D, LVN E and RN A revealed they received training on assistive devices and could articulate the assistive device procedures, including obtaining an order, following the order including time restrictions for the device and monitoring the use of the device. In an interview on 11/19/25 at 4:00p, Treatment Nurse A said she needed to remove assistive devices to observe the skin integrity of the residents.
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