Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings included:
Record review of the admission sheet (undated) for Resident #1 revealed a [AGE] year-old female admitted
to the facility on [DATE] with diagnoses which include alzheimer's disease (a progressive disease that
destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning
and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of
mood swings ranging from depressive lows to manic highs).
Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the BIMS score was 05 out of 15,
which indicated she was severely impaired cognitively. The MDS revealed she was dependent on staff with
toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal
hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent.
Section H0400: Bowel Incontinence was coded (3) always incontinent.
Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the
following:
Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a
timely manner. Performance deficit is related to muscle weakness.
Goal: Resident will participate to the best of their ability and maintain current level of functioning with
activities of daily living (ADLs) through the next review date.
Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up
Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
675046
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
08/16/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x
1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed.
Encourage resident to participate to the fullest extent possible with each interaction and praise when
attempts are made.
Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care
assisted by Wound Care Nurse. CNA J removed Resident #1's brief and tucked it under the resident's
buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the
area and the resident's urinary meatus.
In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at this facility
last month. CNA J said she did not spread Resident #1's labia and clean the resident's meatus during
incontinent care because I changed her diaper before breakfast around 8am. She said the failure placed
the resident at risk for infections.
In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they
provided complete and proper incontinent care each time they perform incontinent care. She said CNAs
were provided training and competency check offs upon hire, quarterly and as needed.
No policy on peri care was provided on exit.
Record review of facility's Nursing Peri-Care Performance Criteria revealed read in part: .FEMALE 10.
Positions waterproof pad under buttocks. 11. Helps to flex knees and spread legs apart. Notes limitation in
positioning. 12. Cleanses the upper thighs. 13. Separates labia minora to expose urethral meatus and
maintains hand position while cleansing. 14. Cleanse in one direction from clean to dirty. 15. Cleanse each
side of labia maiora. 16. Wipe in the direction from perineum to rectum. 17. Use a separate wipe for each
stroke and discard. 18. Discard gloves , hand sanitize or wash hands and apply a clean set of disposable
gloves. 19. Dries perinea! area thoroughly using a different section of the towel for each stroke. 20. Asks
patient/resident to lower legs and assume side lying position. Assists as necessary.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675046
If continuation sheet
Page 2 of 4
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
08/16/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
-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.
Findings included:
Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female
admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease
that destroys memory and other important mental functions), cognitive communication deficit (trouble
reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with
episodes of mood swings ranging from depressive lows to manic highs).
Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score
was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was
dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and
personal hygiene. The MDS revealed .
Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the
following:
Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a
timely manner. Performance deficit is related to muscle weakness.
Goal: Resident will participate to the best of their ability and maintain current level of functioning with
activities of daily living (ADLs) through the next review date.
Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up
Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled
per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist.
Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage
resident to participate to the fullest extent possible with each interaction and praise when attempts are
made.
Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA
J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves.
CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident
over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus.
CNA J removed the soiled brief and discarded it into the trash can sitting
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675046
If continuation sheet
Page 3 of 4
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
08/16/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her
hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched
the Resident's clean dress, brief, and sheets .
In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility
last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not
performing hand hygiene while changing gloves could result in cross contamination. She said she had
completed in-services on infection control at the time of hire.
In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either
washed or sanitized her hands in between gloves change as it placed the resident at risk for infections.
In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist.
She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She
said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their
hands upon entering a resident's room, in between glove changes, and before leaving the resident's room.
In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they
provided complete and proper incontinent care each time they perform incontinent care. She said Wound
Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care
on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty
area prior to moving to a clean area when performing incontinent care. She said these failures were risk for
infection control .
Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand
Hygiene was signed by CNA J.
Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part:
.Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the
spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of
antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or
antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves
.
Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part:
.Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the
use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene
Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling
contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an
antiseptic preparation before performing patient care procedures and when providing care to patients in
isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol
agent before and after patient contact. d. Hands shall be washed in accordance with our facility's
established hand washing procedure .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675046
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the August 16, 2024 survey of Rosenberg Health & Rehabilitation Center?
This was a inspection survey of Rosenberg Health & Rehabilitation Center on August 16, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Rosenberg Health & Rehabilitation Center on August 16, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.