Inspection·May 2, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a level one Pre-admission Screening and Resident Review (PASRR) was revised following admission for one resident (Resident #7) out of 17 sampled residents. There were 58 residents residing in the facility at the time of the survey. Residents Affected - Few The findings Included: During multiple observations starting on 04/29/2024 to 05/02/2024, Resident #13 was observed in the room in bed or seated in a geriatric chair the resident was noted receiving enteral nutrition running at 50 Milliliters per hour (ml/hr.) with water flush of 40 ml/hr. Record Review of Resident #7's most recent Level I PASRR dated 11/15/2022 documented in Section I: PASRR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) other-insomnia. Findings based on documented history were-Section II Other indicators for PASARR screening Decision-Making: All checked - no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV. No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I was completed by the Social Service Director at the facility on 11/15/2022. Review of the Clinical Documentation Physician Query Form dated 01/09/2024 documented: Based on the documentation in the medical record, this resident has the following conditions: Psychotic Disorder, unspecified dementia, gastronomy status and dysphagia. Record review of Resident # 7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI (Serious Mental Illness) or ID (Intellectual Disability) or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS), unable to determine. Section I for Active diagnosis documented Psychiatric/Mood Disorder-Psychotic disorder. In addition, the resident was coded for Psychotic disorder in Section I for Active diagnosis on the Annual MDS dated [DATE] and the Quarterly MDS 's dated 11/17/2022, 2/15/2023, 5/14/2023,11/12/2023, and 2/15/2024- Psychotic Disorder. Section N for Medications documented no medications received from the high-risk drug class. Section O for Special Treatments documented the resident received no special treatments or procedures. Record Review of Resident #7's most recent Psychological Consultation dated 02/17/2022 documented: Mental status examination performed. Recommendations: Discontinue Seroquel 12.5 milligrams and new order for Melatonin 5 milligram at bedtime for the patient. Reassurance was provided to the patient, case discussed with staff. Physician will continue to monitor the patient throughout his hospital course as needed. Further recommendations will follow accordingly. Review of the medical records for Resident #7 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Psychotic disorder with delusions due to known physiological condition. Unspecified psychosis not due to a substance or known physiological condition. Insomnia, unspecified and Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105623 If continuation sheet Page 2 of 3 Printed: 05/28/2026 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 105623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Gables Health Care Center 2525 SW 75th Avenue Miami, FL 33155 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Physician's Orders Sheet for April 2024 revealed Resident #7 had orders that included but not limited to: 08/16/2022- Consult Psychiatry on admission & as needed. Record review of Resident #7's Care Plans Reference Date 04/03/2024 revealed: Resident has an alteration in neurological status r/t (related to) Dementia, dysphagia following other nontraumatic intracranial hemorrhage. Interview on 05/01/24 at 08:00 AM. The Social Services Director (SSD) stated: The resident's most recent PASRR was completed on 11/15/2022, at that time, the resident was not taking any medications for psychosis, so he would not have been coded for psychotic disorder. The resident was admitted on [DATE], readmitted on [DATE], so I have to check his paperwork, the other PASRR dated 8/10/2022 the resident was not coded for psychotic disorder either. The surveyor informed the SSD that the resident was coded for a psychotic disorder on the most recent MDS and also the prior Minimum Data Sets in addition, psychotic disorder is listed on the resident's current medical diagnosis documentation. The SSD then stated she will review the resident's chart and get back to the surveyor. On 05/01/2024 at 09:40 AM; the SSD a PASRR dated 7/27/2020 to the surveyor which indicated diagnosis checked of on the mental illness list-Psychotic Disorder. On 05/01/2024 at 10:03 AM; the Director of Nursing (DON) brought documentation revealing the resident has an active diagnosis of a Psychotic disorder based on the physician's clinical documentation dated 1/9/2024 and stated: That is why the diagnosis is coded on the MDS. Review of the facility's policies and procedures titled admission Criteria revision date March 2019 states: Our facility admits only residents whose medical and nursing care needs can be met. All new admissions and readmissions are screened for mental disorders (MD), Intellectual Disabilities (ID) or related disorders per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105623 If continuation sheet Page 3 of 3