Health inspection·September 20, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 12 confidential residents. The facility failed to ensure 12 of 12 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, were provided access to the Grievance form, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 9/19/2024 at 1:00pm, attendees 12 of 12 confidential residents, stated they did not know the grievance process, they did not know where to obtain or submit a grievance form, they did know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. 12 Residents attended the meeting, the 12 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 9/20/2024 at 12:05pm; according to the facilities' Grievance policy a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings on 9/20/2024 at 12:30pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to Residents and there was no access to submit a Grievance anonymously. Interview with the ADM on 9/20/2024 at 1:18pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was kept in her office. The ADM stated the Residents do not have access to the Grievance form. The ADM stated she completes all Grievances. Page 1 of 9 675716 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The Grievances were completed when a Resident comes to her with a complaint, complaints were shared in Resident Council, and when staff report complaints to her. The ADM stated the Grievance Procedure was not posted for Residents. The ADM stated the Residents cannot file a Grievance anonymously due to the Residents not having access to the Grievance form and having no means of submitting a Grievance form anonymously. The ADM stated she was responsible for assigning a Grievance to a staff member to address, she stated her expectation is Grievances be resolved in 24 hours. The ADM stated Residents who voice a complaint were interviewed by the staff member assigned to resolve the Grievance; she stated this was the first step in resolving the Grievance. These interviews were documented on the Grievance form. The ADM stated the resolution to the Grievance were documented on the Grievance form. The ADM stated the resolution was not presented to the complainant in writing as her policy directs. The ADM stated the resolution was discussed with the complainant one on one. The ADM stated she monitors the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council. Grievance Policy Record Review of the Grievance Policy last updated in 2017. Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint. 2. Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing. 675716 Page 2 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0585 4. Level of Harm - Minimal harm or potential for actual harm Upon admission residents are provided with written information on how to file a grievance. 5. Residents Affected - Many Grievances may be submitted orally or in writing and may be filed anonymously. 6. The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission. 7. The ADM has delegated the responsibility of grievance investigation to the grievance officer who is [NAME]. 8. The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM with five working days of receiving the grievance. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. 10. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The ADM will review the findings with grievance officer to determine what corrective actions need to be taken. 12. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 13. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate 675716 Page 3 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0585 the grievance and report the findings. Level of Harm - Minimal harm or potential for actual harm 14. Residents Affected - Many The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 15. This policy will be provided to the resident or the resident's representative upon request. 675716 Page 4 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

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** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 14 residents (Residents #34) reviewed for care plans as follows: Resident #34 did not have a care plan for PASRR positive or PASRR services. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Record review of Resident #34's face sheet, dated 09/19/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania), bipolar disorder (a mental illness that causes extreme mood swings, affecting a person's energy, activity levels, and concentration), major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), anxiety (feeling of fear and worry), and hypertension (high blood pressure). Record review of Resident #34's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #34 had a BIMS score of 15 which indicated Resident #34's cognition was intact. Section A reflected PASRR screening with serious mental illness. Record review of Resident #34's care plan, dated 08/01/24, revealed no care plan for PASRR or PASRR services. During an interview on 09/19/24 at 10:00 AM with Resident #34, she stated she did receive mental health services and had a case worker. During an interview on 09/20/24 at 11:03 AM with the LVN A, she stated a care plan was a tool used to try to find solutions to resident problems. She stated it contained things like a resident's fall risk, what types of behaviors a resident had and how a resident should be positioned. She stated, I don't look at care plans that often, but I do one on one resident care and most information I need to care for a resident was given to me during morning team meetings. She stated the DON was responsible for updating the care plans. During an interview on 09/20/24 at 11:57 AM with the DON, she stated she was responsible for resident care plans. She stated Resident #34 was PASRR positive and does receive services. She stated Resident #34's PASRR positive and services should have been care planned. She stated PASRR positive, and services were not on the comprehensive care plan but was on the 48-hour baseline care plan. She stated if a resident was PASRR positive it must be care planned. She stated it may have gotten missed due to resident being a new admit. She stated it was included in the 48-hour baseline but did not pull over to the comprehensive care plan and she was not sure why. She stated the care plan was used to explain each resident's individual plan of care. She stated nurses, cna's, nursing administration 675716 Page 5 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and social worker use the care plan. She stated the care plan was part of the electronic health record and was available to all staff. She stated the potential negative outcome could be the resident's plan of care cannot be properly carried out. She stated her expectations were for all the information that was needed to care for the resident should be included in the care plan. She stated she had been trained on how to do care plans. She stated the initial care plane was done then periodic audits were conducted by administration staff in order to assure accuracy of the care plan. During an interview on 09/20/24 at 12:51 PM with the admin, she stated Resident #34 was PASRR positive and was receiving services. She stated there was no reason PASRR should not be care planned. She stated the care plan was used to make sure we have patient centered care that was appropriate for the resident. She stated the potential negative outcome could be failing to meet all the residents care needs. She stated the facility does have a system were administration staff audit the care plans. She stated her expectations were for the care plan to be accurate, so the residents achieve proper care and assure nothing was missed. Record review of the provided facility's policy titled Care Plans, Comprehensive Person-Centered, revised [DATE], reflected: Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical mental and psychosocial well-being. c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights including the right to refuse treatment. d. Describe any specialized services to be provided as a result of PASARR recommendations . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) . 675716 Page 6 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 13 residents (Residents #10, #12, #14, #19, #23) and 1 of 5 staff (MA A) reviewed for infection control. Residents Affected - Some 1. MA A failed to properly clean multi-use medical devices between each resident during medication administration for Resident #10, #12 and #23. 2. MA A failed to sanitize hands between residents during medication administration for Resident #10, #14, #19 and #23. These failures could place residents at risk for spread of infection and cross contamination. Findings included: 1. During a medication pass observation on 09/18/24 at 04:53 PM, MA A took an arm blood pressure device to the room of Resident #10 and took his blood pressure on the left upper arm. She then took the arm blood pressure device and placed it on top of the medication cart. MA A did not sanitize the arm blood pressure device before or after use. During a medication pass observation on 09/18/24 at 05:10 PM, MA A picked up the arm blood pressure device from the top of the medication cart and took it to Resident #12, who was seated in the dining room, and took his blood pressure on the left upper arm. She then took the arm blood pressure device and placed it on top of medication cart. MA A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 09/18/24 at 05:11 PM, MA A picked up a wrist blood pressure device from the top of medication cart and took it to Resident #23, who was seated in the dining room, and took her blood pressure on the right wrist. She then took the wrist blood pressure device and placed in on top of the medication cart. MA A did not sanitize the wrist blood pressure device before or after use. 2. During a medication pass observation on 09/18/24 at 04:55 PM, MA A took the blood pressure of Resident #10 on the left upper arm. MA A did not sanitize her hands after taking Resident #10's blood pressure. MA A prepared a PRN medication for Resident #19 and administered the medication. MA A then returned to Resident #10's room and administered his medications. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/18/24 at 05:11 PM, MA A took the blood pressure of Resident #23 on the right wrist. MA A did not sanitize her hands after taking Resident #23's blood pressure. MA A then prepared and administered medications for Resident #14. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/18/24 at 05:19 PM, MA A prepared and administered medications to Resident #12, who was seated in the dining room. MA A did not sanitize her hands before or after medication administration. 675716 Page 7 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation of medication pass on 09/18/24 at 05:24 PM, MA A prepared and administered medications to Resident #23, who was seated in the dining room. MA A did not sanitize her hands before or after medication administration. During an interview on 09/19/24 at 04:12 PM with MA A, she stated she did not sanitize her hands between each resident during medication pass. MA A stated she did not sanitize the wrist blood pressure device or the arm blood pressure device before or after use on each resident. She stated she was nervous while being observed and forgot to sanitize her hands and the blood pressure devices. MA A stated she should have sanitized her hands and the blood pressure devices between each resident during medication administration. MA A stated she had been trained on proper hand hygiene and proper sanitation of multi-use medical devices through in-services conducted by nursing administration approximately monthly. MA A stated a potential negative outcome for failure to properly sanitize her hands and multi-use medical devices was the spread of germs. During an interview on 09/20/24 at 11:21 AM with the ADM, she stated the DON was responsible for assuring staff were trained on proper hand hygiene and proper sanitizing of multi-use medical devices. She stated hand hygiene should be performed before and after each resident during medication administration. She stated multi-use medical devices should be sanitized after use on each resident. The ADM stated her expectation of staff for proper hand hygiene and sanitizing of multi-use medical devices was that it was done correctly because it was the most important thing. The ADM stated a potential negative outcome for failure to properly sanitize hands and multi-use medical devices was that germs could be passed from resident to resident. During an interview on 09/20/24 at 11:25 AM with the DON, she stated hand hygiene should be performed prior to handling medications and after administering medications. She stated multi-use medical devices should be sanitized after each use and between every resident. The DON stated staff were trained on proper hand hygiene and sanitizing multi-use medical devices through quarterly in-services and yearly skills checks conducted by nursing administration. She stated her expectation of staff for proper hand hygiene and sanitizing of multi-use medical devices was to always follow policy. The DON stated a potential negative outcome for failure to properly sanitize hands and multi-use medical equipment was the spread of infection. Record review of facility-provided staff education records titled Hand Hygiene and Alcohol-Based Hand Rub, dated 07/19/24, revealed MA A performed and met the skills check. Record review of facility-provided in-service training titled Infection Control Report dated 06/21/24, was signed by MA A and eleven other staff members. Record review of facility-provided in-service training titled Infection Control-How to Handwash, dated 02/22/24, was signed by MA A and seventeen other staff members. Record review of the facility-supplied policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 675716 Page 8 of 9 675716 09/20/2024 Post Nursing & Rehab Center 605 W 7th St Post, TX 79356

F 0880 Level of Harm - Minimal harm or potential for actual harm 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Residents Affected - Some 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; 1. After contact with a resident's intact skin; Record review of the facility-supplied policy titled, Administering Medications, revised 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the Procedure 1. Wash your hands. 21. Remain with the resident until all medications have been taken. 23. Perform hand antisepsis. 675716 Page 9 of 9