Rosenberg Health & Rehabilitation Center

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2025-11-20 · Tag F0684 · Complaint investigation · Past Non-Compliance

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2025-03-25 · Tag F0656 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-06-09

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2025-03-25 · Tag F0689 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-06-09

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2025-03-25 · Tag F0740 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-06-09

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2023-12-31 · Tag F0880 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-01-01

Provide and implement an infection prevention and control program.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2023-12-11 · Tag F0656 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-12-31

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2023-12-11 · Tag F0689 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-12-31

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity G — ACTUAL HARM

Survey 2024-05-07 · Tag F0689 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-06-03

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

What this scope/severity letter means: A resident was actually harmed. CMS found real harm occurred, affecting one resident. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2026-01-29 · Tag F0656 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-01-30

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-02-27 · Tag F0755 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-03-05

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-02-27 · Tag F0812 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-03-05

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-02-27 · Tag F0814 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-03-05

Dispose of garbage and refuse properly.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-09-27 · Tag F0585 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-10-02

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-08-21 · Tag F0689 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-08-28

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-08-21 · Tag F0806 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-08-28

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-08-21 · Tag F0812 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-08-28

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-08-16 · Tag F0690 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-08-28

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-08-16 · Tag F0880 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-08-28

Provide and implement an infection prevention and control program.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2024-06-21 · Tag F0661 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-07-17

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-03-19 · Tag F0690 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-04-03

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-12-31 · Tag F0584 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-01-10

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-12-31 · Tag F0655 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-01-10

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2023-12-31 · Tag F0812 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-01-10

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2023-12-15 · Tag F0755 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-12-31

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-12-07 · Tag F0660 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-12-31

Plan the resident's discharge to meet the resident's goals and needs.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works