Every finding on record at Comfort Care Nursing Center

Based on interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an unsupervised exit from the facility, when the resident exited the facility unsupervised and remained outside unattended for approximately two (2) minutes before staff redirected him back into the facility for one (1) of three (3) residents reviewed for supervision. Resident #1 Findings include:A review of the facility's Falls Accidents and Incidents Policy, revised 10/1/25, revealed, Purpose: To promote an environment as free as is possible, of accident hazards over which the facility has control. Scope: Staff to provide adequate supervision and assistive devices to help prevent avoidable accidents and injury.A record review of the facility investigation revealed on 5/8/26 at approximately 8:55 AM, while a visitor was leaving the facility, Resident #1 exited behind the visitor. The investigation revealed Resident #1 was intercepted on the front sidewalk of the facility by the social worker. The investigation included surveillance video that showed Resident #1 was outside the facility and unattended for approximately two (2) minutes before being redirected back into the facility by the social worker. On 5/12/26 at 9:50 AM, during an interview with the Administrator, he revealed on 5/8/26 at 8:55 AM, according to surveillance video, front desk personnel pushed the door buzzer open for visitors. He stated Resident #1 ambulated approximately 80 feet from the facility on the facility sidewalks. He reported as the social worker was parking, she noticed Resident #1 and redirected him back into the facility at 8:57 AM.On 5/12/26 at 12:13 PM, during an interview with Administrative Assistant (AA) #2, she revealed her office was located in the front office area, and she could observe who entered and exited the facility. She confirmed she was working on 5/8/26 at approximately 8:55 AM when Resident #1 exited the facility. She reported AA #1 and herself were responsible for pushing the buzzer for visitors to exit the facility because they were positioned facing the entrance and exit doors. AA #2 stated on the day Resident #1 exited the facility, both she and AA #1 were distracted due to computer issues and were unable to recall who buzzed the visitors out when Resident #1 followed behind. She stated they did not observe Resident #1 exiting the facility and were unaware until they were notified the resident was outside the facility. On 5/12/26 at 12:30 PM, during an interview with Social Services, she revealed on 5/8/26 at approximately 8:57 AM, while driving into the facility parking lot, she observed Resident #1 on the sidewalk in front of the two double-door entrance doors. She confirmed as the social worker and being familiar with the residents, she was aware Resident #1 should not have been outside alone. She stated she immediately approached Resident #1 and redirected him back into the facility. She confirmed Resident #1 appeared confused and was dressed appropriately for the weather. She further confirmed the weather that day was cool and clear with no rain.On 5/12/26 at 1:41 PM, during an interview with AA #1, she revealed her office was located in the front office area, and she could observe who entered and exited the facility. She confirmed she was working on 5/8/26 at approximately 8:55 AM when Resident #1 exited the facility. AA #1 confirmed she was responsible for pushing the buzzer to allow visitors to enter and exit the facility because she was positioned facing the entrance and exit doors. She stated on the day Resident #1 exited the facility, both she and AA #2 were distracted due to computer issues and were unable to determine which one of them buzzed the visitors out. She stated she did not observe Resident #1 exiting the facility.On 5/12/26 at 2:30 PM, during an interview with the Director of Nursing (DON), she revealed Resident #1 did not have a history of wandering and had not previously been identified as being at risk for elopement.A record review of the admission Record revealed the facility admitted Resident #1 on 12/25/25 with diagnoses including Dementia without Behavioral Disturbance.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident's cognition was severely impaired.A record review of the Elopement Risk Evaluation revealed Resident #1 was assessed on 3/8/26 and determined not to be at risk for wandering.

Based on observation, interview and facility policy review the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to foods not dated, foods not labeled, foods not properly sealed, overly ripe produce and unsanitary handling of ready to eat foods for two (2) of two (2) kitchen observations. Findings include: A review of the facility's policy, Food Safety Policy. Reviewed 08/27/2025, revealed, Policy Explanation and Compliance Guidelines.Facility staff shall inspect all food.Labeling, dating, and monitoring.food, including but not limited to leftovers, so it is used by its use-by-date or.discarded; and Keeping foods covered or in tight containers.Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands. On 09/29/2025 at 10:30 AM, during an initial kitchen tour and interview with the Food Service Supervisor (FSS) observed Refrigerator #1 had four (4) trays containing prepared individual salads, individual dished out bowls of pudding, and individual dished out bowls of fruit, with no date label, (2) clam shell disposable plates containing, what the FSS identified as the staff's food, with no label and within close enough proximity as to be touching the residents' food, (2) pans of what the FSS identified as blueberry cobbler with no date or label, one (1) plastic container containing fruit cocktail with no date, (1) plastic storage container containing (2) shelled boiled eggs, with a facility Prepared date of 9/18/25 and a facility Use by date of 9/22/25, a container of lemon wedges with a facility Prepared date of 9/24/25 and a Use by date of 9/27/25, (1) opened, prefilled bag of prepared whipped topping with no opened on date and manufacturer's instructions reading 14 days refrigerated. Refrigerator #3 revealed (1) plastic bin containing raw chicken tenders in a plastic bag, with the lid off the bin and the plastic bag open, leaving the chicken exposed, with no staff presently using the chicken, (1) opened container of cheese slices with the lid opened and the cheese visibly dried out, 11 quarts of strawberries that contained fruit with white bio-growth, three (3) oranges that were overly ripe, soft and pliable to the touch, (1) unopened container of prechopped onion with no date. An observation of the dry bins revealed the lids for bins containing sugar, rice and cornmeal were pushed back leaving the food exposed. An observation of the pantry revealed (1) opened bag of grits with the bag folded down and not securely closed. The FSS acknowledged the deficient storage and labeling concerns in the kitchen. The FSS noted it is his responsibility to ensure the safety of the kitchens' food supply. The FSS reported that the kitchen staff are in-serviced on food safety twice a month. The FSS noted he will implement a system for getting together with the kitchen staff and doing rounds to ensure food storage is done correctly. On 09/30/2025 at 10:20 AM, during a second tour of the kitchen an observation of the lower shelf of the beverage prep area revealed an opened bottle of lemon juice with the manufacturer's instructions that read Refrigerate after opening. No staff were currently preparing beverages at the time of this observation. An observation of the food services line revealed the Dishwasher picking up several pieces of cornbread with her gloved hand and placing them on residents' plates. An observation of the Food Server (FS) revealed she used her gloved hand to move bread on a resident's plate. The FS was also observed using her fingers to push noodles back into a bowl of chicken noodle soup. An interview with the dishwasher revealed she affirmed that she picked up the bread with her gloved hand. The dishwasher revealed she knew not to do this but forgot. The dishwasher reported the importance of not touching ready to eat food with hands is prevent contamination. The dishwasher reported that the kitchen staff are in-serviced every 6 months on food safety. The FS acknowledged touching food on the resident's plates with her gloved hand. The FS affirmed that the reason for not doing this is to not spread germs. The FS stated the staff are in-serviced on food safety 2x a month. The FSS acknowledged the improperly stored lemon juice and confirmed that it is normally kept on the shelf in the beverage prep area. The FSS also acknowledged the two staff members touching ready to eat foods with their gloved hands. The FSS stated his expectation is to have all kitchen staff receive certification in food safety. The FSS reported that he expects the staff to serve residents the best they can. On 10/02/2025 at 11:58 AM, during an interview the Administrator acknowledged the improperly stored foods, exposed foods, and unsanitary handling of ready-to-eat foods. The Administrator noted it is the responsibility of all kitchen staff to maintain food quality and sanitation. The Administrator stated he expects the kitchen staff to date and label foods appropriately, monitor and throw away expired foods, and keep foods covered to eliminate the risk of exposure to debris falling into the food. The Administrator reported that he expects the kitchen staff to follow food service standards.

Based on interviews and record reviews, and facility policy review the facility failed to ensure that staff reported allegations of verbal abuse involving two (2) of three (3) residents reviewed for verbal abuse (Resident #66 and #93), and failed to report multiple allegations of misappropriation of resident property (money) involving five (5) of 14 residents in Resident Council (Residents #5, #8, #17, #38, and #81) to the State Agency (SA), as required by federal regulations. Findings include: A record review of the facility's policy titled Abuse, Neglect, and Exploitation Policy, revised 8/26/25, revealed: It is the policy of this facility to provide protection of the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, misappropriation of resident property . Reporting/Response 1. All alleged violations.will be report to the Administrator and/or the Director of Nursing who will report to the appropriate law enforcement officials when applicable, Mississippi State Department of Health Division of Health Facilities Licensure and Certification and Medicaid Fraud Control Unit/Office of the Attorney General (AGO) within specific timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. During an interview, on 10/2/25 at 9:31 AM, the Administrator confirmed that multiple residents had reported funds stolen. He stated that, based on available information, the facility determined residents were unable to verify the exact amounts lost, and therefore reimbursement was not provided. However, he acknowledged the facility's responsibility to ensure resident safety and affirmed that if residents had clearly documented the missing amounts, the facility would have been obligated to issue reimbursement either by check or cash, with proof of payment. When asked by the State Agency (SA) why the incident had not been reported, the Administrator responded: I did not know I was supposed to report this to the State Agency. This is my first time dealing with residents having their money stolen. Resident #66 On 9/29/25 at 11:43 AM, during an interview, Resident #66 stated that Licensed Practical Nurse (LPN)# 1 raised her voice during the night shift while attempting to administer a newly ordered medication. The resident described the nurse's tone as demeaning and intimidating and stated that she felt talked down to like a child. Resident #66 expressed fear of retaliation, noting concern for other residents who may not be able to speak up. On 9/29/25 at 2:45 PM, during an interview, the resident's roommate (Resident# 94) confirmed the incident, stating the nurse was loud and intimidating, and that her behavior was uncalled for. On 9/30/25 at 3:30 PM, during an interview, Resident #93 described the nurse's tone as rough and intimidating, stating she talks to us like we're kids and throws her weight around. Resident #93 added that such behavior was inappropriate for long-term care. On 9/30/25 at 4:05 PM, during an interview, Certified Nursing Assistant (CAN) #1 reported that LPN 1 was extremely negative, loud, vulgar, and insulting to staff during the same shift. She recalled the nurse saying, Y'all some sorry Mother#####rs towards her and other staff, and described her as intimidating to both staff and residents. In an interview on 9/30/25 at 1:43 PM, LPN# 1 admitted that Resident #66 was resistant to taking a new medication, and acknowledged speaking loudly, stating, That's just how I talk, though she claimed to have lowered her voice after the resident objected. In an interview on 9/30/25 at 1:28 PM, Registered Nurse (RN) #2 stated the nurse and resident had words, and confirmed the resident had reported the nurse being loud. However, she did not report the incident to the Director of Nursing (DON), stating, It wasn't a big deal. In an interview on 9/30/25 at 2:52 PM, the Director of Nursing (DON) stated that she had not been informed of the incident. She confirmed that staff are required to report such allegations and that the nurse would have been removed from the resident's care pending an investigation. She noted the nurse had a second, unrelated complaint the same night from the CNA. A review of the admission Record for Resident #66 revealed that the facility admitted Resident #66 on 12/15/23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction.

Based on interview, record review, and facility policy review, the facility failed to review and resolve multiple resident grievances in a timely and effective manner, resulting in ongoing unaddressed environmental concerns expressed during three (3) of 3 consecutive months of Resident Council meetings. Findings include:A review of the Grievance Policy review date 11/17/16 revealed, Purpose To ensure the resident.right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without the fear of discrimination or reprisal . Responsibilities .The facility will review grievances in a timely manner and must make prompt efforts to resolve grievances. The facility will keep the resident appropriately apprised of its progress toward resolution .A record review of the Resident Council Meeting Minutes Reports dated 7/10/25, 8/14/25, and 9/11/25, revealed concerns expressed by the residents during the council meetings for housekeeping concerns regarding floors, trash, and cleaning the rooms in general.Resident #14During an initial interview on 9/29/25 at 11:46 AM, Resident #14 reported that the facility does not clean the floors, empty the trash, or perform general housekeeping duties on weekends. As a result, rooms are often left unclean throughout the weekend, with no trash removal and unwashed floors. She stated that this concern has been raised during resident council meetings but has not received a response.A record review of the admission Record revealed the facility admitted the Resident #14 on 10/29/24 with diagnoses including hyperlipidemia, and unspecified atrial fibrillation.A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment.Resident #96On 9/29/25 at 2:00 PM, Resident #96 shared that she frequently experiences accidents on the floor due to loose bowel. On weekends, she is left to manage the odor and appearance of these incidents until staff return on Monday, as rooms are not cleaned during that time. She reported the issue to staff but stated that the housekeeping concern remains unresolved.A record review of the admission Record revealed the facility admitted Resident # 96 on 7/22/24 with diagnoses including malignant neoplasm of colon, unspecified.A record review of the MDS with an ARD of 8/27/25 revealed a BIMS score of 15 indicating the resident was cognitively intact.On 9/30/25 at 10:00 AM, during the resident council meeting, the State Agency (SA) asked for a show of hands from residents who still had complaints about housekeeping. All residents present raised their hands unanimously. Several voiced concerns, including statements such as, They don't do a good job of cleaning the rooms, particularly on the weekends.On 9/30/25 at approximately 12:43 PM, the Housekeeping Manager explained that her staff is responsible for entering resident rooms at least twice daily, once in the morning and once in the evening, to ensure cleanliness. She stated that trash should be emptied, and floors mopped or swept during these visits. However, she acknowledged that the department is currently understaffed and does not have personnel assigned to work weekends, which contributes to the complaints. While efforts are made to assist on weekends, she confirmed there is no dedicated staff for that time. She expressed awareness of the concerns raised during resident council meetings and emphasized that she is doing her best to address them. Ultimately, she stated that without additional staff, she is unable to make further improvements.On approximately 10/1/25 at 12:11 PM, the Administrator confirmed awareness of the ongoing housekeeping complaints voiced by residents during council meetings. He stated that he has brought the issue to the attention of the Housekeeping Supervisor, who indicated she would work on a solution. He acknowledged that staffing shortages are a contributing factor and that efforts are underway to resolve them. Nonetheless, he affirmed that it is the facility's responsibility to ensure rooms are properly cleaned and that resident grievances should be addressed promptly to prevent them from becoming persistent concerns.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications and biologicals were securely stored to prevent access by unauthorized individuals for one (1) of four (4) days of survey.Findings include:A review of the facility's policy titled Controlled Medication Storage Accountability and Proper Destruction Policy, revised 5/17/18, revealed: .2. The outer lock on the medication cart is locked at all times when not in direct view of the nurse.During an observation on 9/29/25 at 11:23 AM, the wound care cart located on the 200 Hall was noted to be unlocked and unattended, with wound cleanser left unsecured on top of the cart. The cart remained unlocked for fifteen (15) minutes, until 11:38 AM when Registered Nurse (RN)#1 arrived, placed the unsecured cleanser inside the cart, and then locked it.During an interview with RN #1 on 9/29/25 at 3:51 PM, she stated the cart should always be locked but explained that the keypad locking mechanism had been malfunctioning, requiring her to use a manual key. She acknowledged that she forgot to lock the cart after her last use. RN #1 also confirmed that the cart contained medications including: Nystatin (antifungal ointment and powder), Santyl (collagenase - enzymatic debriding agent), Dakin's solution (diluted bleach-based cleanser), and other wound care agents. She stated that these medications, if ingested, could cause gastrointestinal distress and would likely result in a visit to the emergency room.In an interview on 9/29/25 at 3:51 PM, the Director of Nursing (DON) confirmed the expectation that all treatment carts remain locked when not in use, citing the potential for harm to residents who may have accessed the wound care products such as Dakin's solution and Santyl. She added that the facility had active hallway traffic, and an unlocked cart could present a risk.In an interview conducted on 10/2/25 at 2:05 PM, the Administrator also confirmed the facility's expectation that carts are to be locked at all times when not in use, and that medications or supplies should not be left on top of the cart.

Based on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of resident funds and failed to implement corrective action or reimburse residents after funds were reported missing, affecting five (5) of 14 residents interviewed in Resident Council (Residents #5, #8, #17, #38, and #81).Findings include:A record review of the policy, Abuse Neglect and Exploitation Policy latest review date of 8/26/25 reveals, Purpose: It is the policy of this facility to provide protection of the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, misappropriation of resident property .On 9/30/25 at 10:15 AM, during a Resident Council meeting, Resident #85 (Council President) stated to the State Agency (SA) that multiple residents had reported their money was stolen a few months/weeks ago. She stated she notified the Administrator, who said he was busy, and then reported the issue to the Director of Nursing (DON), who told her all residents should report to the Social Service Director. Resident #85 stated no updates had been provided to her or the residents on their missing money and expressed outrage, stating we have rights, and the facility needs to give them their money back. She revealed the specific residents that came to her are Resident #5, Resident#8, Resident #17, Resident #38 but knows were several more due to talk with other residents. Resident #5On 10/2/25 at 10:38 AM, Resident #5 reported to the SA that $50 had been taken from him. He stated the money was inside a white envelope in his pants pocket. He believes someone from the laundry department may have collected his pants along with the envelope. He shared that no one has informed him of the outcome or offered reimbursement. While he expressed a desire to have the money returned, he also acknowledged the importance of being more cautious about where he stores his funds.A record review of the email from the Social Service Director to the Administrator on 8/11/25 indicating the resident had reported $50 missing on 8/8/25.A record review of the admission Record revealed the facility admitted the resident on 3/26/24 with diagnoses including atherosclerotic heart disease.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/25 revealed a Brief Interview for Mental Status score (BIMS) of eleven (11) indicating the resident had moderate cognitive impairment.Resident #8At 10:41 AM on 10/2/25, Resident #8 explained that he keeps his money in a drawer to save for outings. He noticed that $40 was missing and reported it to the Resident Council President, who assured him she would notify staff. He stated that no one followed up with him or discussed reimbursement. He expressed feeling uneasy and shared that it would be a blessing if the facility returned the money, as it came from his personal savings.A record review of the admission Record revealed the facility admitted Resident #8 on 9/22/22 with diagnoses including heart failure.A record review of the MDS with an ARD of 8/12/25 revealed BIMS score of 15 indicating the resident was cognitively intact. Resident #17On 10/2/25 at 8:42 AM, Resident #17 stated that a little over $100 had been stolen from her some time ago. She reported the incident to a staff member in social services but has not received a response or reimbursement. She expressed sadness that such incidents occur, especially given residents limited financial resources. She added that the experience made her feel unsafe, leaving valuables in her room and that she would greatly appreciate having the money returned. A record review of the statement captured by a staff member dated 6/25/25 confirms resident concern of missing money of $110.A record review of the admission Record revealed the facility admitted Resident #17 on 3/14/19 with diagnoses including generalized anxiety disorder.A record review of the MDS with an ARD of 7/22/25 revealed a BIMS score of 15 indicating the resident was cognitively intact. Resident #38On 10/2/25 at 8:52 AM, Resident #38 reported that several weeks prior, she discovered $87 missing from her purse when preparing to pay for Walmart items delivered by the activities team. Only a $1 bill and some change remained. She stated that she reported the incident to the council president and two security officers, who assured her they would investigate. As of the interview, she had not received any updates or reimbursement. She expressed feeling deeply discouraged and emphasized that the money was taken without her consent. A record review of the statement given to staff on 6/25/25 confirms that resident stated $87 was missing from her purse.A record review of the admission Record revealed the facility admitted Resident #38 on 5/2/22 with diagnoses including Anemia.A record review of the MDS with an ARD of 9/8/25 revealed a BIMS score of eight (8) which indicated the resident had moderate cognitive impairment.Resident #81A record review of the statement made to staff by Resident #81 on 7/7/25 and then again to security personnel that $15 dollars was stolen from her wallet.A record review of the admission Record revealed the facility admitted Resident #81 on 11/15/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.A record review of the MDS with an ARD of 9/15/25 revealed a BIMS score of 15 indicating the resident was cognitively intact. On 10/2/25 at 9:19 AM, the Social Services Director, a Licensed Master Social Worker, explained that her role in the investigation was to collect resident statements and forward them to the Administrator. She noted that residents consistently recalled the amounts missing and appeared credible in their reports. She confirmed that, to date, residents have not been reimbursed, and she is unaware of the investigation's outcome.On 10/2/25 at 9:31AM, in an interview the Administrator confirmed that several residents had their money stolen from the facility. He revealed from what he gathered the residents could not confirm the amounts that were stolen so the facility did not refund their money. However, he said he understands it is still the facility's responsibility to keep the residents safe because it is their home. He said that if he had knowledge that the residents knew exactly how much they were missing the facility would be obliged to return the money. He said they would give them a check or give them cash to show proof of reimbursement.

Based on interviews and record review, the facility failed to ensure residents' right to be free from verbal abuse by staff for two (2) of three (3) residents reviewed for abuse (Residents #66 and #93).Findings include:A review of facility policy Abuse Neglect and Exploitation Policy with a reviewed date of 8/26/25 revealed Purpose: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, misappropriation of resident property and exploitation.Definitions: 3. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.During an interview on 9/29/25 at 11:43 AM, Resident #66 reported that night shift Licensed Practical Nurse (LPN)#1 raised her voice during a medication pass and spoke in a demeaning and intimidating tone. The resident stated she felt as though she was talked down to like a child. She also expressed fear of retaliation and concern for other residents who might not be able to speak up.During an interview on 9/29/25 at 2:45 PM, Resident #66's roommate, confirmed that LPN#1 was loud and intimidating and said the interaction was uncalled for and rude.On 9/30/25 at 1:28 PM, Registered Nurse (RN) #2 stated the nurse and resident had words, and confirmed the resident had reported the nurse being loud but that was just her personality.During an interview on 9/30/25 at 1:43 PM, LPN#1 admitted that Resident #66 was resistant to taking a new medication and acknowledged speaking loudly, stating, That's just how I talk, though she claimed to have lowered her voice after the resident objected.During an interview on 9/30/25 at 2:52 PM, the Director of Nursing (DON) stated that she had not been informed of the incident, but she noted the nurse had a second, unrelated complaint the same night from the CNA about verbal abuse towards herself and other staff. On 9/30/25 at 3:15 PM, Resident #66 reiterated her account, stating that the nurse argued with her at 6:00 AM about taking a newly prescribed medication, which upset her stomach and gave her gastrointestinal symptoms. When she questioned the timing and asked about speaking to the physician, she said the nurse responded in a sarcastic tone, stating, How many times do I have to educate you before you take your meds? Resident #66 again stated this experience made her feel afraid, degraded, and intimidated.During an interview on 9/30/25 at 3:30 PM, Resident #93 stated, The nurse talks to us in a rough tone of voice, throws her weight around, talks to us like we're kids, and scares us by using her authority. That's not how you talk to someone. She identified herself as a former Certified Nursing Assistant (CNA) and emphasized that the nurse's behavior was inappropriate for long-term care.During an interview on 9/30/25 at 4:05 PM, CNA #1 reported that LPN#1 was extremely negative, loud, vulgar, and insulting to staff during the same shift. She recalled the nurse saying, Y'all some sorry Mother#####rs towards her and other staff and described her as intimidating to both staff and residents.During an interview on 10/2/25 at 12:05 PM, the facility scheduler, stated that CNA #1, who rarely complains, reported on Monday morning that LPN#1 had verbally abused her during Sunday's night shift, cussing her out and calling her names. The scheduler stated the facility usually handles these types of reports by separating the staff on different halls or shifts.A record review of the admission Record for Resident # 66 revealed that the facility admitted Resident #66 on 12/15/23 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction.A record review of Resident #66's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.A record review of the September 2025 electronic Medicine Administration Record (eMAR) dated for Resident#66 revealed the medicine Resident #66 referred to was document as being given by LPN #1 at 6AM on the day the incident occurred (9/28/25).A record review of the MDS with an ARD of 9/8/25 revealed a BIMS score of 15 which indicated Resident #93 was cognitively intact.

Based on interviews, record review, and facility policy review the facility failed to ensure that residents were treated with dignity and respect by licensed nursing staff for two (2) of four (4) residents reviewed for resident rights (Resident #66 and #93).Findings Include:A record review of facility policy titled Resident's Rights Policy revealed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.On 9/29/25 at 11:43 AM, Resident #66 reported that night shift Licensed Practical Nurse (LPN)#1 raised her voice during a medication pass and spoke in a demeaning and intimidating tone. The resident stated she felt as though she was talked down to like a child. She also expressed fear of retaliation and concern for other residents who might not be able to speak up.On 9/29/25 at 2:45 PM, Resident #66's roommate, confirmed that LPN#1 was loud and intimidating and said the interaction was uncalled for and rude.On 9/30/25 at 3:15 PM, Resident #66 reiterated her account, stating that the nurse argued with her at 6:00 AM about taking a newly prescribed medication, which was upsetting her stomach. When she questioned the timing and asked about speaking to the physician, she said the nurse responded in a sarcastic tone, stating, How many times do I have to educate you before you take your meds? Resident #66 again stated this experience made her feel afraid, degraded, and intimidated.On 9/30/25 at 3:30 PM, Resident #93 stated, The nurse talks to us in a rough tone of voice, throws her weight around, talks to us like we're kids, and scares us by using her authority. That's not how you talk to someone. She identified herself as a former Certified Nursing Assistant (CNA) and emphasized that the nurse's behavior was inappropriate for long-term care.On 9/30/25 at 4:05 PM, CNA #1 reported that LPN#1 had also spoken to staff in a demeaning and vulgar manner, using profanity and insults. CNA #1 said she no longer wanted to work with the nurse due to her intimidating behavior.On 10/2/25 at 12:05 PM, in an interview with the facility scheduler, she stated that CNA #1, who rarely complains, reported on Monday morning that LPN#1 had verbally abused her during Sunday's night shift, cussing her out and calling her names. The scheduler stated the facility usually handles these types of reports by separating the staff on different halls or shifts.On 10/2/25 at 12:30 PM, in an interview with both the Administrator and the DON, they stated all residents have the right to be treated with dignity and respect.A review of the admission Record for resident #66 revealed that the facility admitted Resident #66 on 12/15/23 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/25 revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.A review of the admission Record for Resident # 93 indicated she was admitted on [DATE] with diagnoses which included acute on chronic systolic congestive heart failure.A record review of the MDS with an ARD of 9/8/25 revealed a BIMS score of 15 which indicated Resident #93 was cognitively intact.

Based on record review, interview, and facility policy review, the facility failed to identify, assess, and coordinate behavioral health services for three (3) of three (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving these services. Specifically, the facility allowed a Licensed Certified Social Worker (LCSW) to provide ongoing cognitive behavioral therapy within the facility without physician oversight, formal referral, or interdisciplinary coordination in which she accepted self-referred residents, regardless of whether clinical need had been identified. Findings Included: A review of the facility's policy, Dementia and Behavioral Health Services, reviewed 02/28/2024, revealed, .It is the policy of this facility that all residents receive the appropriate treatment and services for .necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .Discussion .6. Specialized services and supports will vary based on the individual's abilities and challenges related to their condition . On 6/11/2025 at 11:00 AM, during a phone interview, the complainant stated that a Licensed Clinical Social Worker (LCSW), employed by the local hospital's behavioral health program, came to the facility weekly and provided therapy sessions to several residents. The complainant explained that the LCSW refused to disclose the names of the residents she was seeing, which prevented the facility from coordinating care, obtaining physician oversight, or monitoring for changes in residents' psychosocial or behavioral health status. She expressed concern that residents may have been receiving therapy without proper clinical justification or oversight, and that the lack of transparency and interdisciplinary involvement could result in unmet needs, fragmented care, or inappropriate continuation of services for vulnerable residents. On 6/12/2025 at 10:00 AM, during an interview with the Social Services Director, she confirmed that the Licensed Clinical Social Worker (LCSW) enters the facility every Thursday to provide therapy services. However, she stated the LCSW does not communicate with facility staff, the Nurse Practitioner (NP), or the physician regarding which residents are receiving services. As a result, the facility is unable to conduct appropriate psychosocial assessments or implement monitoring interventions to evaluate the effectiveness or necessity of the therapy. On 6/12/2025 at 10:30 AM, during an interview with the LCSW, she stated that she had provided therapy services to approximately 21 residents. She explained that all referrals were self-referral by residents who were cognitively intact, with Brief Interview for Mental Status (BIMS) scores of 13 or higher. The LCSW stated that, due to confidentiality, she does not inform facility staff or medical personnel of the residents receiving therapy. She confirmed that the residents independently request services and that she has a pamphlet in the facility's front lobby containing information about her services and contact details. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she confirmed that the LCSW did not communicate with nursing staff regarding which residents were receiving therapy. Therefore, there was no coordination of care since there were no physician orders, no behavioral health monitoring or follow-up, as the staff was unaware that therapy services were being provided. On 6/12/2025 at 11:15 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that the facility does not receive any information regarding the residents receiving therapy from the LCSW and therefore the facility was unable to initiate monitoring or coordinate care for those residents. On 6/12/25 at 11:30 AM, during an interview, the Administrator confirmed the facility did not coordinate care or provide oversight of the behavioral health services provided by the LCSW which could result in care that conflicts with residents' overall treatment goals. On 6/12/2025 at 1:27 PM, during an interview with the Nurse Practitioner (NP)/Psychiatric Provider, she confirmed that she was not aware the Licensed Clinical Social Worker (LCSW) was providing therapy services to Residents #4, #5, or #6. She stated that she had not issued any referrals for therapy and had not conducted any follow-up monitoring for those residents. On 6/12/2025 at 1:45 PM, during an interview with the Physician, he confirmed that he had not ordered behavioral health therapy for Residents #4, #5, or #6 and was unaware they were receiving such services. He stated that without this information, he was unable to assess their psychosocial status or provide appropriate medical oversight. A record review of a pamphlet displayed in the facility's front lobby titled NOW OFFERING Psychotherapy Services revealed a brochure containing provider details and contact information for the Licensed Clinical Social Worker (LCSW) offering behavioral health services. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that included all services provided to address the psychosocial needs of three (3) of three (3) sampled residents receiving individual psychosocial therapy (Residents #4, #5, and #6), with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to include ongoing psychosocial therapy services provided by the Licensed Clinical Social Worker (LCSW) in the residents care plans to ensure coordination of care, consistent monitoring, and individualized interventions based on the residents' psychosocial needs. Findings included: A review of the facility's Comprehensive Person-Centered Care Plan Policy, reviewed on 1/24/2024, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered plan of care for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . During a phone interview on 6/11/25 at 11:00 AM, the complainant revealed that there are no care plans related to behavioral therapy received by residents seen at the facility by a LCSW. She explained the LCSW is not employed by the nursing home facility (3rd Party Provider) and she refuses to share any information regarding the residents to which she provides services. On 6/12/2025 at 10:00 AM, during an interview with the facility's Social Services Director, she confirmed there are no behavioral care plan interventions that includes the services provided by the LCSW that visits the facility. On 6/12/2025 at 10:30 AM, during an interview with the LCSW, she confirmed that she has seen approximately 21 residents in the facility, and she does not provide the name of the residents or any information to the facility due to confidentiality. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she stated that there was no documentation or Physician's Orders provided to the facility by the LCSW and as a result, care plans were not developed for residents receiving behavioral therapy. On 6/12/2025 at 11:00 AM, during an interview with Licensed Practical Nurse (LPN)/MDS Coordinator #1, she confirmed that Residents #4, #5, and #6 did not have care plans reflecting services provided by the LCSW. She stated that comprehensive care plans are important to ensure residents receive individualized care. She further stated that although Section D of the MDS captured mood concerns on occasion, these were not cross-referenced with therapy services provided by the LCSW, since the facility was not informed of the sessions. On 6/12/2025 at 11:30 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that all services provided to residents, including psychosocial therapy, should be incorporated into the resident's care plan. She stated the LCSW has refused to collaborate with the team or provide documentation, which prevented the facility from creating care plans reflecting these services. On 6/12/25 at 11:45 AM, during an interview with the Administrator, he confirmed there is no indication that the interdisciplinary team was involved in developing or reviewing care plans related to psychosocial therapy services provided by the LCSW. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. A record review of the medical records for Resident #4, Resident #5, and Resident #6 revealed there were no care plan interventions developed reflecting behavioral therapy received by the residents from the LCSW. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on interview, record review, and facility policy review, the facility failed to notify the physician and the resident's representative of the initiation of psychosocial services for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to ensure that the physician and resident representative (RR) were informed when 1:1 psychosocial therapy services were initiated by a third-party provider. Findings Included: A review of the facility's Resident Rights Notification of Changes Policy, reviewed date 05/30/2025 revealed, It is the policy of (Proper Name of Facility) to notify the resident; consult with the physician; and notify, consistent with his or her authority, the resident representative of changes as discussed in the policy . On 6/11/25 at 11:00 AM, a phone interview with the complainant revealed that there is a Licensed Certified Social Worker (LCSW) that is not employed by the nursing home facility (3rd Party Provider) who comes to the facility to provide psychosocial therapy to several residents. The complainant stated that LCSW refuses to share the names of the residents she provides services to, which prevents the facility from notifying the residents' Responsible Representatives (RRs) and the physician of new treatments or interventions. The complainant expressed concern that when the physician is not notified, there is no opportunity to review, approve, or coordinate the therapy with the resident's overall medical plan of care. This could result in duplicate or conflicting treatments, overlooked medication considerations, or a missed opportunity to address any underlying conditions. Additionally, the complainant was concerned that failure to notify the RR limits their ability to monitor the resident's care and make informed decisions on their behalf and advocate effectively for the resident's needs, especially if the resident has limited insight. On 6/12/25 at 10:00 AM, in an interview with the facility's Social Services staff member, she confirmed that the LCSW is from the local hospital and enters the facility on Thursdays to provide therapy on residents within the facility. She does not inform the facility's staff, Psychiatric Nurse Practitioner (NP), or the physician who she is providing therapy for. Therefore the facility is unable to notify the RR of any new orders or treatments of her services. On 6/12/25 at 10:30 AM, in an interview, the LCSW confirmed that she has provided the behavioral services to approximately 21 residents at the facility. She revealed that the residents are self-referrals, and they all have a Brief Interview for Mental Status (BIMS) score of 13 or greater. The LCSW stated that she does not provide any information regarding these residents to the nursing staff or the facility, because it is confidential. On 6/12/25 at 10:45 PM, during an interview, Registered Nurse (RN) #1 stated that she was not aware of which residents were receiving psychosocial therapy services from the LCSW in the facility. She confirmed that, as a result, no physician orders had been obtained for the service, and the facility had not notified the residents' RRs of the initiation of therapy. RN #1 acknowledged that the facility has a written policy requiring physician involvement and RR notification prior to any changes in treatment and confirmed that this policy had not been followed for residents receiving psychosocial services from the LCSW. On 6/12/25 at 11:10 AM, during an interview, the Administrator confirmed that the LCSW was providing psychosocial therapy services to residents within the facility. The Administrator stated that all referrals were initiated by the residents themselves. He acknowledged that the facility did not follow its policy requiring RR and physician notification. On 6/12/25 at 1:27 PM, during an interview, the Nurse Practitioner/Psych confirmed that she was not aware that the LCSW evaluated or performed sessions with Resident #4, #5, and #6. She explained there was no referral provided to the facility on which residents the LCSW was providing treatment. On 6/12/25 at 1:45 PM, during an interview with the Physician, he confirmed that he was not aware of and had not issued any referrals for Residents #4, #5, or #6 to receive psychosocial evaluations or treatment. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. A record review of the medical records for Resident #4, Resident #5, and Resident #6 revealed there were no documentation indicating the RRs or they physician's were notified regarding behavioral therapy received by the residents. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression . Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to obtain a physician's order for ongoing psychosocial therapy services provided by a third party Licensed Clinical Social Worker (LCSW), resulting in services being delivered without appropriate physician oversight. Findings included: A review of the facility policy titled, Physician Orders, reviewed 01/24/2024, revealed, .Scope: Physician's orders that will be obtained, noted, and implemented appropriately . During a phone interview on 6/11/25 at 11:00 AM, the complainant revealed that there are no Physician's Orders for residents who are seen at the facility by a LCSW for behavioral therapy. She explained the LCSW is not employed by the nursing home facility (3rd Party Provider) and she refuses to share the names of the residents to which she provides services. During an interview on 6/12/2025 at 10:00 AM, the facility's Social Services Director confirmed there were no Physician's Orders for behavioral therapy services that are provided to the residents by the visiting LCSW. During an interview on 6/12/2025 at 10:30 AM, the LCSW confirmed she does not provide resident names to the facility due to confidentiality nor provides them with any documentation of her sessions with the residents. She stated she has seen approximately 21 residents in the facility. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she confirmed there are no Physician's Orders for the residents who are seen by the LCSW regarding behavioral services. On 6/12/2025 at 11:30 AM, during an interview with the Assistant Director of Nursing (A-DON), she confirmed that all services provided to residents, including psychosocial therapy, should have a Physician's Order. On 6/12/25 at 1:45 PM, during an interview with the Physician, he confirmed there were no orders or referrals for Resident #4, #5, and #6 and without physician orders, the facility was unable to ensure that services provided by the LCSW were appropriate to the resident's diagnoses or current mental health status. A record review of the facility's statement, dated 6/12/25, and signed by the Administrator revealed, The facility did not have a referral for (Proper Name of LCSW), no care plan, and no notification of resident representative . regarding Resident #4, Resident #5, and Resident #6. A record review of the LCSW resident service list revealed that she had provided psychosocial services to 21 residents, including Resident #4, Resident #5, and Resident #6. A record review of the medical records for Resident #4, Resident #5, and Resident #6 revealed there were no Physician's Orders initiated reflecting behavioral therapy received by the residents. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on interview, record review, and facility policy review, the facility failed to ensure complete and readily accessible medical records were maintained for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the therapist maintained resident therapy documentation separately from the facility's medical record and did not share or integrate the documentation into the residents' facility medical records. Findings included: A review of the facility's policy titled, Medical And Personal Resident Records, reviewed 01/24/2024, revealed, .It is the policy .that the resident's personal and medical records shall be maintained in accordance with professional standards and practice Discussion: 1. The medical record shall be completely and accurately documented, readily accessible .to facilitate retrieval and compiling of information . On 6/11/2025 at 11:00 AM, during a phone interview with the complainant, she stated that a Licensed Clinical Social Worker (LCSW), employed by the local hospital's behavioral health department, provided therapy to several residents and stored all related documentation in a locked cabinet to which only the LCSW had access. The complainant reported that the LCSW refused to allow the Interdisciplinary Team (IDT) to review these records. As a result, the facility's medical record for each resident receiving these services was incomplete due to lack of access to pertinent clinical information. On 6/12/2025 at 10:00 AM, during an interview with the facility Social Services Director, she confirmed that the Licensed Clinical Social Worker (LCSW) visits the facility on Thursdays and independently provides therapy to residents. She stated that the LCSW does not share progress notes or any other documentation related to the services being provided. On 6/12/2025 at 10:30 AM, during an interview with the Licensed Clinical Social Worker (LCSW), she stated that she had provided therapy services to approximately 21 residents in the facility. The LCSW confirmed that she does not provide the facility with any documentation related to the services rendered, citing confidentiality. On 6/12/2025 at 10:45 AM, during an interview with Registered Nurse (RN) #1, she stated that she was not aware of which residents LCSW was treating, and there was no documentation available within the facility ' s medical record system regarding the therapy services rendered by the LCSW. On 6/12/2025 at 11:30 AM, during an interview with the Assistant Director of Nursing (A-DON), she confirmed that all services provided to residents, including psychosocial therapy, should be incorporated into the resident ' s computerized charting system at the facility. The absence of documentation in the facility ' s record system prevented staff, physicians, and interdisciplinary team members from being aware of ongoing therapy services. Resident #4 A record review of the admission Record revealed the facility admitted Resident #4 on 4/18/24 with current diagnoses including Fibromyalgia. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Further review of Section D and Section E indicated there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Resident #4 received Cognitive Behavioral Therapy weekly and bi-weekly as needed on the following dates: December 5, 2024, December 12, 2024, December 19, 2024, January 9, 2025, January 16, 2025, January 22, 2025, January 30, 2025, February 20, 2025, February 27, 2025, March 6, 2025, and March 19, 2025 for Major Depressive Disorder. Patient declined visits on February 6, 2025 and February 13, 2025. Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 5/30/23 with current diagnoses including Sacral Spina Bifida without Hydrocephalus. A record review of Optional MDS with an ARD of 5/13/25, revealed Resident #5 had a BIMS score of 15, which indicated he was cognitively intact. Further review of Section D and Section E revealed there were no behaviors exhibited by the resident and there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided once a month to Resident #5 on December 19, 2024, January 9, 2025, February 6, 2025, March 6, 2025 and May 29, 2025 for Depression. Patient declined April 2025 visit. Patient discharged from services on May 29, 2025, due to completion of treatment plan. Resident #6 A record review of the admission Record revealed the facility admitted Resident #6 on 12/15/23 with current diagnoses including Hemiplegia and Hemiparesis. A record review of the Optional MDS with an ARD of 4/15/25 revealed Resident #6 had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of Section D and Section E revealed the resident did not exhibit any behaviors or there were no mood symptoms present. A record review of a written statement, dated 6/12/25 and signed by the LCSW revealed that Cognitive Behavioral Therapy was provided bi-weekly to Resident #6 on January 16, 2025, January 22, 2025, February 6, 2025, February 20, 2025, March 6, 2025, and March 20, 2025 and May 29, 2025 for Depression. Patient declined visits from April 3, 2025-May 29, 2025. Patient continues to be seen bi-weekly in accordance with treatment plan.

Based on staff interview and record review, the facility failed to electronically submit accurate direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for one (1) of three (3) months reviewed. December 2023 Findings include: A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility had triggered for Four or More Days Within the Quarter with no RN (Registered Nurse) Hours and Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage from 12/2/23 to 12/31/23. Record review of facility policy Nurse Staffing Information, revised 11/14/23, revealed it did not address the accurate submission of PBJ data. On 5/13/24 at 12:48 PM, the Business Office Coordinator stated she was unaware the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY (Fiscal Year) 2024. She explained she was responsible for entering the PBJ data for the facility and kept the receipts which indicated the data was sent. She stated she did not receive any type of error message, warning, or email after the information was submitted that would have indicated the information was not accurate. During an interview on 5/14/24 at 10:48 AM, with the Director of Nursing (DON), she stated she was not aware there was an error with the data that was submitted to PBJ for the first quarter of FY 2024. The DON explained she was responsible for creating the nursing schedules and confirmed the facility always had adequate nursing staff and had 24-hour RN coverage. She stated she had not received any type of email or had any indication staffing data for December 2023 had not been submitted accurately. On 5/14/24 at 1:51 PM, the Administrator stated she was unaware there was an issue related to the accuracy of the PBJ data that was submitted to CMS for the first quarter of FY 2024. The Administrator confirmed the Business Office Coordinator was responsible for entering and submitting the PBJ staffing data for the facility. The Administrator said there was an interface error that occurred, and the staffing data was not collected from 12/2/23 through 12/31/23. She confirmed there was no shortage of nursing staff or RN coverage for December 2023. The Administrator reported that she would not have known the data was entered incorrectly because she did not receive any feedback by email or otherwise that would have alerted her than an error had been made, but ultimately it was the responsibility of the facility to ensure the information submitted was accurate. 50751