Inspection·November 20, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some or other medical device (a palm guard is a device used for moderate to severe contractures to help prevent skin breakdown in the palm). Record review of CR #1's Progress Note documenting skin issues dated 11/4/25 revealed Treatment Nurse B indicated CR #1 did not have an external device, and there were no documented skin issues on his left hand. Record review of CR #1's Nurse Progress Note dated 11/6/25 revealed CR #1 was sent to an acute care hospital for g-tube replacement. Record review of CR #1's After Visit Summary from an acute care hospital dated 11/10/25 revealed he had his feeding tube replaced. The summary included instruction for CR #1 to start taking Ceftin (an antibiotic medication), 1 tablet in the morning and 1 tablet in the evening administered by feeding tube for 5 days. Record review of CR #1's nurse progress note dated 11/14/25 revealed NP A visited CR #1 for a readmission evaluation day #3. (CR #1) was sent to (acute care hospital) on 11/6/2025 due to dislodgement of his PEG tube. At the time of hospitalization he was treated with IV antibiotic for elevated WBC count and suspected pneumonia. After stabilization and PEG tube replacement patient is send (sic) back to the facility on [DATE]. Record review of CR #1's Treatment Administration Record dated 11/1/25 to 11/30/25 revealed Treatment Nurse A documented a head-to-toe skin assessment daily between 11/11/25 and 11/14/25 and on 11/17/25. Treatment Nurse A indicated that there were no changes to CR #1's skin integrity. Record review of Resident #1's Progress Note documenting skin issues dated 11/17/25 completed by Treatment Nurse A indicated CR #1 did not have an external device, and there were no documented skin issues on his left hand. Record review of CR #1's nurse progress note dated 11/17/25 at 9:00pm completed by LVN A revealed, During scheduled medication pass at this time, I observed the resident left hand between thumb/index finger was swollen, red with what appeared to be skin tear, (resident) had on a hand brace in between his thumb/index area. At this (sic) I slowly pulled the brace back and noticed dry blood. At this time, I attempted to assess and clean the area, but resident yelled in pain. I provided his schedule (Morphine) 1mL was administered along with all other scheduled medications. Placed call to.(Advanced Nurse Practitioner). Received order to transfer to (acute care hospital). Record review of CR #1's SBAR Communication Form dated 11/17/25 revealed LVN A documented that CR #1 had a swollen left thumb that started on 11/17/25. The form noted things that make the condition or symptom worse are: hand cuff. Things that make the condition or symptom better are: removing the hand cuff. LVN A documented that the hand cuff is very tight between thumb causing swelling. LVN A notified NP B and NP B recommended CR #1 was sent to the hospital. Record review of CR #1's acute care hospital record dated 11/18/25 at 5:01am revealed an inpatient consult to the hospitalist. MD B noted CR #1 was brought to the hospital due to left hand pain and an open wound. Patient was reportedly put in wrist restraints with thumb hole which cut into the thenar surface. Patient noted to have bleeding and reportedly had foul-smelling discharge.had his wound cleaned and dressed. He was then admitted for further workup and management. assessment and plan: Open wound of thumb with complication.cellulitis (a common, deep skin infection caused by bacteria entering through a break in the skin) of finger of left hand, leukocytosis (a condition characterized by a higher-than-normal white blood cell count and is typically a sign of the body responding to an infection, inflammation or injury). Record review of CR #1's acute care hospital record dated 11/18/25 at 12:41pm revealed an inpatient consult to general surgery. During a physical exam, MD C noted CR #1's left hand wound involving the 1st web space was deep and almost to the bone. There was no active bleeding, and the wound appeared somewhat chronic; has a foul smell without purulence (the state of containing or forming pus). MD C noted the evaluation of the hand was limited by the contracted positioning of the digits. The patient is confused and slightly combative on exam. Given the chronicity, we do not recommend closure of this wound, and it should continue to heal by secondary intention. Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675046 If continuation sheet Page 2 of 6 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 11/20/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some CR #1's acute care hospital record dated 11/19/25 revealed an inpatient consult for wound care. The document revealed he presented to the hospital with an open wound on his left hand present on admission. The wound on his hand was secondary to restraints. The wrist restraints cut into patient's left thumb. There is a concern for bleeding and malodorous drainage. The wound was described as a linear laceration into the thenar wound bed (sic) pink, moist, wound margin was circumscribed periwound intact (the skin around a wound is healthy, unbroken, and clearly defined without any signs of damage). There is depth to the wound. And the wound extends into patient's R (sic) palm. Contractures noted of the fingers. The document was completed by MD A. Record review of CR #1's acute care hospital record revealed a photo of his left hand (undated). The hand was shaped like a balled-up fist. Someone was pulling the thumb away from his palm area and the inside of the wound was visible. There was a medical device on his hand that wrapped around from underneath and on top of his thumb that extended out to the top of his hand. It was approximately 2 inches wide. The device had a Velcro component, and the tag was visible displaying the brand name. The device was stained with a dark brown substance where it met the thumb. The thenar web space was lacerated and part of the device was in the laceration. His thumb was red, swollen and had a patch of dried blood and some layers of skin were gone. Record review of CR #1's acute care hospital record revealed a photo of his left hand (undated). The hand was shaped like a balled-up fist. There was no device near his thumb. The thenar web space was lacerated and extended down into his hand toward the bone in his thumb. The thumb was lacerated underneath his thumb where it met his wrist. The laceration was covered in red blood. This thumb was red, swollen, and had a patch of dried blood and some layers of skin were gone. In an interview on 11/19/25 at 4:30pm, LVN B said CR #1's left arm and left hand were contracted. He said his left arm was held close to his chest. He said CR #1 liked to be under a blanket because he was cold and did not like when staff moved the blanket. He said he was not aware of CR #1 having a palm guard or other medical device on his hand because he was always covered. In a telephone interview on 11/20/25 at 7:05pm NP A said she saw CR #1 a few times last week. She said when she visited, CR #1 asked if she would pray with him, and she took both of his hands. She said she did not notice anything wrong with his hands during that time. She said, Maybe something happened overnight. She said CR #1 moved his hands a lot. She said she was not informed by a nurse of a wound to his hand. In an interview on 11/19/25 at 4:00pm, Treatment Nurse A stated she completed a skin assessment of CR #1 about 1 to 2 days before he went to the hospital. She said she saw he had a device on his hand but did not remove it to observe his skin. She said at that time, she did not see blood, edema (swelling caused by excess fluid trapped in your body's tissues) or notice any foul odors. In a telephone interview on 11/19/25 at 2:42pm, LVN A said CR #1 did not like to be shuffled around and liked to be covered with a blanket. She said his left arm was contracted. She said it was bent and always resting on his shoulder. CR #1 had a hand splint/device to open his hand to treat a contracture. She said she was unsure who put the device on. She said she had seen him use the device since she started in July 2025. She said she had not received training on the use of devices and did not monitor their use in his treatment record. She said when she worked with CR #1, she looked at the device on his hand but did not notice there was anything wrong before 11/17/25. She said on 11/17/25, she raised his bed so she could administer his medications. She said when she pulled the sheet back, she saw that his hand was swollen and red with dried blood on it. She said she attempted to remove the device and clean it, but he was in a lot of pain. She said she could not determine how bad the wound was, but said the device was stuck in his hand. She said she called NP B and received a recommendation to send him to the hospital. In a telephone interview on 11/21/25 at 11:35am, MD A said she saw CR #1 at the hospital. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675046 If continuation sheet Page 3 of 6 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 11/20/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she did not see him immediately on admission, so she did not see the device on his hand. She said she reviewed the pictures of his hand in his medical record. She said the brace may have been too tight and was there for too long, so it would dig into his skin. She said she described the wound as a laceration in her note because she saw him after the device was removed from his hand. She said the wound could have been a medical device related pressure wound. She said she could not get measurements of the wound because of his hand contracture and the pain it would have caused. In an observation on 11/19/25 at 1:20pm at the acute care hospital, revealed CR #1 was lying in a bed with his eyes closed. His left hand had a thick bandage wrapped around it. His arm was positioned on his chest and his hand was near his left collar bone. In an interview on 11/19/25 at 9:26am, the Hospital RN said CR #1 was in their hospital on [DATE] due to a dislodged g-tube. She said when he left on 11/10/25, he had no injuries to his hand. She said when Resident #1 was seen in the hospital on [DATE], a device was on his hand and was deeply embedded in his hand where the device wrapped around his thumb. She said there was no way the injury occurred in one day. In an interview on 11/19/25 at 2:55pm, the DON said he heard about CR #1's injury from a nurse at the hospital. He said someone in therapy placed the palm protector device on Resident #1's left hand on 11/11/25. He said it was determined that the device was left on his hand from 11/11/25 to 11/17/25. He said when they discovered yesterday on 11/18/25 that Resident #1 did not have an order for the device, they initiated a performance improvement plan. He said a device should have an order, care plan and monitoring in place. In an observation and interview on 11/19/25 at 3:07pm, the Therapy Director said she was the only full-time occupational therapist. She said an occupational therapist evaluated a resident to determine a need for a palm protector device. She said she did not recommend a palm protector for CR #1. She said she could not find a recommendation for a palm protector in CR #1's medical record. She said a palm protector was used when a hand was contracted to protect the palm from the fingers. She said they were used from 4 to 8 hours. She said the risk of using it longer would be skin breakdown. The Therapy Director showed the investigator a palm protector. The palm protector was made out of a fleece-like material. It was placed on the hand using a Velcro strap and a hole for the thumb. When placed, there was a pad in-between the palm and the fingers. In an interview on 11/20/25 at 2:22pm, the Therapy Director said when a resident was receiving therapy services, the therapy team monitored the use of a palm guard device, including placed it then removed it. She said if a resident was not receiving therapy services, the nursing staff were responsible for monitoring. She said CR #1 was under the care of hospice and the nurses were required to complete skin checks. In an interview on 11/19/25 at 4:45pm, CNA A said CR #1 required total assistance with care. She said he did not like when they touched his left arm or hand. She said CR #1 had a brace/device on his left hand for about one month. She said it was in place during the entirety of her shifts from 6am-6pm. She said they were not informed of what type of brace it was. She said it was gold in color and would have noticed if it had blood on it. She said she did not notice any type of injury to his hand. In an interview on 11/19/25 at 6:15pm, RN A said CR #1's left hand and arm were contracted, and his arm was pushed against his chest. She said he had a palm guard on his hand to protect his palm from his fingers. She said sometimes she would check to make sure it was not too tight. She said she did not take it off. She said the device was white so it would be noticeable if it was bleeding. She said she did not notice anything wrong with it. She said she did not know who put the device on his hand or when it occurred. In an interview on 11/19/25 at 6:27pm, CNA B said she saw something on CR #1's hand but could not say what it was. She said she did not notice any issues with his contracture or the device. In an interview on 11/20/25 at 3:15pm, COTA A said her responsibilities at the facility were to carry out the occupational (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675046 If continuation sheet Page 4 of 6 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 11/20/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some therapist's recommendations for residents. She said she did not make recommendations for treatment. She said CR #1 had a palm protector for a while. She said he was on and off therapy services, and at some point it was recommended. She said she did not put the device on CR #1's hand in the last month. She said she would only see a resident if they were on therapy services. She said CR #1 had not been on services for about 2 months. In an interview on 11/20/25 at 3:37pm, the ADON said it was difficult to assess CR #1 because he did not like to be bothered and pulled back from the nurses. He said he did not know about CR #1's device or injury until he was admitted to the hospital. He said residents with recommendations for a brace or a device should have physician's orders, monitoring and updated care plan. In an interview on 11/20/25 at 3:57pm, COTA B said her responsibilities at the facility were to carry out the occupational therapist's recommendations for residents. She said she did not make recommendations for treatment. She said if a resident was seen for contracture management, she would complete hand care, place the recommended device, monitor for the allotted time, then take it off. She said the devices were not available to a resident unless there was a recommendation for one and it was ordered by the rehabilitation department. She said if a resident was on therapy services, the COTA would monitor the device, and if the resident was not on therapy, the nursing staff would monitor the device. She said the device should be monitored to ensure skin damage did not occur. She said she had not seen CR #1 in over a month. In a telephone interview on 11/20/25 at 4:36pm, LVN C said he cared for CR #1 when he returned from the hospital after 11/11/25. He said when CR #1 returned from the hospital, he had a dressing on his left contracted hand. He said when he saw CR #1's hand on or about 11/11/25, his hand was brown in color, but the wound was not open. He said the dressing was clean and NP A assessed him. He said NP A did not say anything or give any orders. He said he thought CR #1 laid on his left side for too long and that could have caused swelling and skin breakdown. When asked if it was possible that the dressing he was referring to was a contracture management device, he said he was not sure, but it could have been. He said he was not sure who put it on CR #1's hand. He said CR #1 had a brace for his hand a few months ago. He said he was admitted from the hospital with an order for antibiotics. He said he thought the antibiotic prescription was for a possible wound infection, but he did not do the admission assessment so he was unsure. In a telephone interview on 11/20/25 at 4:47pm, CNA C said she worked with CR #1 on 11/13/25, 11/14/25, and 11/17/25. She said CR #1 was always lying on his left side and it was contracted. She said on 11/13/25, she noticed he had a splint on his hand. She said on 11/14/25, when she turned him to change his clothing, she noticed his thumb was swollen and reddish-purple in color. She said she opened his hand and saw it was raw and puss was coming out of his hand. She said she told LVN C. She said LVN C told her he was on antibiotics and there was no further discussion. She said when she returned on 11/17/25, the wound on CR #1's hand looked the same as it did on 11/14/25. In an interview on 11/20/25 at 5:36pm, CNA D said he noticed CR #1's hand was contracted and there was a cloth on his hand but did not get close enough to observe it. Record review of the facility's Skin Management Policy dated 2/1/2014 revealed in part, A comprehensive evaluation of a patient's skin status requires evaluations by the nursing staff, registered dietician, social services, activity and rehabilitation team. if new skin alterations of any type are identified through skin observation or skin evaluations/assessments the physician and family is notified. Physician orders are obtained. The patient is reviewed by the interdisciplinary team and a plan of care initiated. It was determined these failures placed CR #1 in an Immediate Jeopardy (IJ) situation from 11/11/25 to 11/18/25. The Administrator was notified and provided with the IJ template 11/19/25 at 7:07pm. The facility took the following action to correct the non-compliance on 11/18/25: Record review of a Performance Improvement Plan dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675046 If continuation sheet Page 5 of 6 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 11/20/2025 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 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. Event ID: Facility ID: 675046 If continuation sheet Page 6 of 6