Health inspection·June 21, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .Social Worker spoke to [name] who is the RP and family member for [CR#1]. SW asked if he would like for a referral to be submitted to [facility name], and he stated that he would like the referral to be sent. Referral to [facility name] was sent to [name], the admissions coordinator . Record review of CR #1's clinical record revealed no evidence of discharge planning and no discharge assessment. Record review and interview on 06/21/24 at 1:37p.m., RN AA said nurses initiated the discharge summary and the DON reviewed and signed for completion. RN AA reviewed CR#1's electronic medical records with the State Surveyor. RN AA said, I don't see the discharge Summary for CR#1. Record review and interview on 06/21/24 at 2:30p.m., ADON B said at the time of discharge nurses entered the DC orders and filled out the Discharge Summary form. The State Surveyor reviewed CR#1's EMR with ADON B. ADON B said she completed the functional abilities and goals discharge form today (6/21/24) but failed to complete the Discharge summary and plan of care form. ADON B said the expectation for the nurses were to fill these forms out within 24 to 72 hours of discharge. CR#2 Record review of CR#2's face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure ( a condition that develops when your heart doesn't pump enough blood for your body's needs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). CR#2 was discharged on 06/04/2024. Record review of CR#2's Care Plan initiated 01/19/2024 and updated on 06/05/2024 revealed the following: Focus: Resident was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning was not needed. Goal: Resident and families wishes will be honored through the next review date. Interventions: Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed. Record review of CR#2's Discharge MDS dated [DATE] revealed Section A0310. Types of Assessment: F. Entry/discharge reporting coded-10: Discharge assessment-return not anticipated. Section A2105. Discharge Status coded-04: Short-Term General Hospital. Record review of CR#2 nurses noted dated 06/04/24 at 8:35p.m., revealed read in part: .Res found smoking marijuana in his car at the parking lot. Administrator confronted the res about this behavior, and the res was little aggressive. Administrator called 911. The police arrived, upon searching the res car, the police discovered that the res had a firearm in his car per Administrator. The police took the res. The writer notified the Md . Record review of CR #2's clinical record revealed no evidence of discharge planning and no discharge assessment. Record review and interview on 06/21/24 at 3:05p.m., ADON A said prior to being planned/unplanned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675046 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosenberg Health & Rehabilitation Center 1419 Mahlman St Rosenberg, TX 77471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discharge nurses initiated the discharge summary and each discipline were responsible for completing their own part. ADON A said he expected the interdisciplinary discharge summaries to be completed and sent with the resident at the time of discharge. ADON A said discharge assessments were important to be completed so the resident would know his or her limitations, and recommendations from other departments for example PT for discharge. ADON A said, usually the DON was responsible for closing out discharge documents, but the DON had been out for couple of days in training. ADON A said the ADONs and nurses could also go in assessments and complete/close the forms as well. ADON A said he completed the functional abilities and goals discharge form, discharge summary and plan of care form for CR#2 today (6/21/24). In an interview on 06/21/24 at 3:38p.m., with the Administrator, she said she reviewed CR#1's Social Worker's notes and CR#1 was transferred to another facility. She said, I don't know where CR#2 went after the law enforcement took him from the facility. Record review of facility's Discharge Planning policy dated (12/6/2016) revealed read in part: .Discharge Summary: Post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675046 If continuation sheet Page 3 of 3