Inspection·January 29, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ACRONYMS:BIMS: Brief Interview of Mental StatusRN: Registered NurseDON: Director of NursingADON: Assistant Director of NursingMDS: Minimum Data SetADM: AdministratorBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment to ensure that resident's care plan was reviewed and revised by the interdisciplinary team to address 1 of 4 residents (Resident # 1's) allegation.The facility failed to ensure that Resident # 1's care plan was revised to address her sexual allegation This failure could place 94 residents at risk of being sexually abused.Record review of Resident # 1's admission face sheet dated 01/08/2026, retrieved on 01/28/2026 at 10:17 a.m., revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. Her diagnoses included: Bipolar disorder (mental health condition characterized by severe mood swings ranging from extreme high to low. Mild cognitive impairment (decline in memory. Thinking, and judgement ranging from mild to severe. Major depressive disorder (mood disorder characterized by persistent sadness, loss of interest and low energy. Anxiety (excessive persistent fear or worry that interferes with daily life). Record review of Resident # ‘s quarterly MDS dated [DATE], retrieved 01/28/2026 at 10:17 a.m., revealed for section C0500 the resident's BIMS score was 15 indicating the resident was cognitively intact. For section E0100: Behavior, Resident # 1 was coded with no hallucinations or delusions. Record review of Resident # 1's dated 01/08/2026 retrieved on 01/28/2026 at 10:35 a.m., revealed she uses psychotropic medications which included antipsychotics and antidepressants related to her diagnoses of depression and anxiety. This was initiated on 05/14/2025 and revised on 07/15/2025 with goal for Resident #1 to be free from cognitive behavior/behavior impairment. The intervention was -staff to monitor side effects such as, mania, hostility and rage and impulsive behavior and hallucination. In an interview with RN B on 01/28/2026 at 12:41 p.m., she said, she did not know why the care plan for Resident # 1 was not updated after she made the sexual allegation. RN B said the MDS Coordinator and other management staff are responsible for the care plan. She said the nurses are not directly responsible for the care plan. Nurses can see what is on the care plan and implement the orders. In an interview with MDS Coordinator at 2:25 p.m. on 01/28/2026, she said developing and updating the care plan is the responsibility of the MDS Coordinator, the ADON and the DON. She agreed she knew Resident ‘s sexual abuse incident. She reviewed the care plan for Resident # 1from 09/24/2025 through January 28th, 2026, and said the care plan was not updated to reflect Resident ‘s allegation of sexual abuse by a staff member. She said, I cannot tell why it was not updated, I do not have an answer to that at this time. In an interview with ADON A, at 04:56 p.m. on 01/28/2026, he said all nurse managers and the MDS Coordinator are responsible for developing and updating the care plans. He said the care plans are updated so staff can better care for the residents. The consequences of failure to update the care plan for Resident # 1 is the fact that the incident might happen again. In an interview with RN A, at 12: (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 2 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 01/29/2026 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)