Rosenberg Health & Rehabilitation Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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Rosenberg Health & Rehabilitation Center in Rosenberg, TX 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 Rosenberg, TX, (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 Rosenberg Health & Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.