Health inspection·September 27, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances for 1 of 3 (Resident#1) residents reviewed for grievances. -The facility failed to establish a grievance policy that includes the right to obtain a written decision regarding a resident's grievance. -The facility did not provide a written decision to Resident #1 who filed grievances. These failures could place residents at risk for feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included: Observation on 09/27/2024 at 2:01p.m., of the posting near the Receptionist area titled Abuse, Neglect and Grievances revealed the posting included the Administrator's name, title, and phone number. Record Review of Resident #1's face sheet, dated 9/27/2024, revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record Review of Resident #1's quarterly MDS assessment, dated 8/13/2024, revealed Resident #1 had a BIMS score of 15 out of 15 which indicated Resident #1 was cognitively intact. Record Review of Resident #1's care plan initiated 12/09/2023 and revised on 12/11/2023 revealed the following: Focus: Resident is in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments.Goal: Resident and family's wishes will be honored through next review date. Interventions: Observe for change in conditions that may affect long-term care goals and notify the Page 1 of 3 675046 675046 09/27/2024 Rosenberg Health & Rehabilitation Center 1419 Mahlman St Rosenberg, TX 77471

F 0585 Level of Harm - Minimal harm or potential for actual harm physician and responsible party as needed. Discuss the need for continuing long-term care placement with the resident or family as indicated or requested. Encourage and allow the resident or family to discuss feelings and concerns regarding long-term care placement. Discuss with the resident or family the level of care that would be needed to safely return to an assisted living facility, group home, or the community when indicated or Residents Affected - Few requested. Record Review of the facility's Grievance log (June 2024 to September 2024) revealed Resident#1 filed a grievance on 09/03/2024 and 09/04/2024 with the facility that included patient care and medication administration. The resolution date for the grievance was 09/03/2024 and 09/04/2024 and documentation revealed that the resident was verbally informed of their decision regarding the grievance by the DON, SW, Administrator, but no documentation of written notification was given to Resident #1 or Resident #1's representative. In an interview on 09/27/2024 at 9:30a.m., Resident #1 stated that she had filed two grievances with the facility on 09/03/24 and 09/04/24. Resident #1 stated she had made several attempts with the SW and the Administrator to request copies that the grievance was concluded but had not received any documentation. Resident#1 stated she was told by the Administrator that it was the company's policy not to provide written documentation of the decision regarding the grievance. Resident#1 stated she had filed grievances regarding insulin administration and patient care, and it was her right to view the resolution of the grievances. Resident#1 stated she felt ignored not getting written decisions about her grievances. In an interview on 09/27/2024 at 11:46a.m., with the Administrator, he stated the grievance form was an internal document. Resident/family and not even state Surveyor can have access to the grievance form. It's company's policy. Surveyor asked what if the resident/family or Surveyor request to see the documentation of the decision regarding the grievance. The Administrator stated, they can't. In an interview on 09/27/2024 at 1:10p.m., The SW stated Resident#1 had requested written explanation of the findings of the grievance several times. SW stated she did not give Resident #1 a written explanation of the findings of the grievance. SW stated they had a meeting with Resident#1, Regional Administrator, Administer and her as witness of the conversation. The Regional Administrator explained to the resident normally it's not what we practice. Grievance form is more of internal document, so it is not uploaded to the resident's file. It's not a medical record. SW stated the grievances form goes in the grievance file and when state surveyors ask for it, she was to give it in the form of the grievance log. SW said that a possible negative outcome for not giving a resident written notification for a filed grievance would be that a resident may not feel that the grievance was resolved. In an interview on 09/27/2024 at 1:50 p.m., Interim DON stated the Administrator was the facility's abuse coordinator. Interim DON stated the process for grievance was interview staff/resident, investigate, resolve, and provide explanation to the resident if alert and or family. Interim DON stated, I don't think there is anything that would be preventing us from giving a copy. Interim DON stated that a possible negative outcome for not providing written documentation of the resolution would be that the resident would feel a lapse of communication in the facility, that a resident may forget that they were talked to about the grievance and feel that their grievance was not heard. Record Review of facility's Grievance Policy (Revision Date: 11/19/2016, 7/22/2023) reflected in 675046 Page 2 of 3 675046 09/27/2024 Rosenberg Health & Rehabilitation Center 1419 Mahlman St Rosenberg, TX 77471

F 0585 Level of Harm - Minimal harm or potential for actual harm part: .The Administrator (grievances officer) is responsible for the following: Validates designee follows up with the resident/family regarding resolution or explanation. Ensure that residents either individually or through postings throughout the facility are aware of: The right to file grievances orally, or in writing in the language he/ she understands, Residents Affected - Few The right to file grievances anonymously, The contact information of grievance official Ensure that the grievance officer's information is posted to include: his/her name, business address (mailing and e-mail) and business phone number. A reasonable expected time frame for completing the review of the grievance. The contact information of independent entities with which grievances may be filed. E.g.: The pertinent state agency, Quality improvement Organization, State Survey Agency and State Long Term Care Ombudsman program or protection and advocacy system. Provide a copy of the grievance policy to the resident upon request . The grievance policy did not mention the right to obtain a written decision regarding his or her grievance. 675046 Page 3 of 3