Safety Report: Rosenberg Health & Rehabilitation Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
7Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
7Requirements cited on more than one inspection
K
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
K
Government finding: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies · Tag F740
K
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
K
Government finding: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F656
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
K
Government finding: Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F880
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
J
Government finding: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F656
Citations by topic
0Abuse, neglect & exploitation
3Infection control
2Medications & pharmacy
4Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (4) than in the cycle before (6).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 4 | March 25, 2025; August 21, 2024; May 7, 2024; December 11, 2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 3 | January 29, 2026; March 25, 2025; December 11, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | February 27, 2025; August 21, 2024; December 31, 2023 |
| Provide and implement an infection prevention and control program. (F880) | 3 | August 16, 2024; December 31, 2023; December 7, 2023 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | November 20, 2025; October 6, 2023 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | February 27, 2025; December 15, 2023 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 2 | August 16, 2024; March 19, 2024 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| November 20, 2025 | Fine | $17,345 |
| February 27, 2025 | Payment Denial | Payment denial for 13 days, starting May 27, 2025 |
| February 27, 2025 | Fine | $25,587 |
| December 7, 2023 | Fine | $39,884 |
| December 7, 2023 | Fine | $14,518 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
June 10, 2026 — 2 citations · complaint investigation
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected June 15, 2026
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · complaint · corrected June 15, 2026
January 29, 2026 — 1 citation · complaint investigation
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected January 30, 2026
November 20, 2025 — 1 citation (includes serious) · complaint investigation
K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F684 · complaint
March 25, 2025 — 3 citations (includes serious) · complaint investigation
K
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F740 · complaint · corrected June 9, 2025
K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 9, 2025
K
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Immediate jeopardy to resident health or safety · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected June 9, 2025
February 27, 2025 — 3 citations
E
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F814 · corrected March 5, 2025
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected March 5, 2025
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected March 5, 2025
September 27, 2024 — 1 citation · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · complaint · corrected October 2, 2024
August 21, 2024 — 3 citations · complaint investigation
D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F812 · complaint · corrected August 28, 2024
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · complaint · corrected August 28, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected August 28, 2024
August 16, 2024 — 2 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected August 28, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected August 28, 2024
June 21, 2024 — 1 citation · complaint investigation
E
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F661 · complaint · corrected July 17, 2024
May 7, 2024 — 1 citation (includes serious) · complaint investigation
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 3, 2024
March 19, 2024 — 1 citation · complaint investigation
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected April 3, 2024
December 31, 2023 — 4 citations (includes serious)
K
Provide and implement an infection prevention and control program.
Immediate jeopardy to resident health or safety · Pattern · Infection Control Deficiencies · F880 · complaint · corrected January 1, 2024
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected January 10, 2024
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected January 10, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected January 10, 2024
December 15, 2023 — 1 citation · complaint investigation
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · complaint · corrected December 31, 2023
December 11, 2023 — 2 citations (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected December 31, 2023
J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Immediate jeopardy to resident health or safety · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected December 31, 2023
December 7, 2023 — 2 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected December 31, 2023
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · complaint · corrected December 31, 2023
October 6, 2023 — 1 citation · complaint investigation
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected October 27, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare