Health inspection·August 18, 2022

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review the facility failed to refer a resident with a mental disorder to the appropriative state-designated authority for a level II PASARR (preadmission screening and resident review) evaluation and determination for 1 of 1 residents sampled for PASARR. (Resident #1) Residents Affected - Few The findings include: Review of resident #1's medical record revealed an admission date of 9/16/16. Review of resident #1's PASARR dated 6/2/21 and completed by the Director of Nursing (DON) revealed section A. page 2: resident has anxiety disorder and depressive disorder and is currently receiving services for mental illness. Page 5 section 4, indicates no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASARR evaluation not required. The resident record revealed the resident had medical diagnosis to include psychosis 6/3/19, bipolar type Schizoaffective disorder 9/16/16, major depressive disorder 9/16/16, and generalized anxiety disorder 9/16/16. The record did not contain evidence of a level II PASARR. An interview was conducted with the DON on 8/16/22 at approximately 2:04 PM. The DON stated she checked the wrong box on the PASARR and the facility did not request a level II PASARR for the resident. Review of the facility policy for Preadmission Screening and Resident Review (document name SS-402 revised 11/8/21) revealed The center will ensure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Page 1 of 2 105148 105148 08/18/2022 Aviata at Emerald Shores 626 N Tyndall Pkwy Callaway, FL 32404

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to implement effective monitoring of bowel activity for 2 of 2 sampled residents receiving routine or as needed medications for constipation. (Resident #1 and #6) Residents Affected - Few The findings include: Review of resident #1's record revealed the resident was admitted to the facility on [DATE]. The current physician orders revealed the resident received Lactulose solution 10 grams/milliliter (ml), with instruction to give 30 ml by mouth every 8 hours daily for constipation beginning on 11/28/21 and Linzess capsule 290 micrograms by mouth every morning for chronic constipation beginning on 6/6/22. Review of the electronic record bowel movement documentation for the last 14 days revealed no bowel movement had been documented from 8/6/22 through 8/16/22. An interview was conducted with resident #1 on 8/16/22 at 3:50 PM. She stated she had not had a bowel movement in 4 days. Review of resident #6's record revealed the resident was admitted to the facility on [DATE]. The current physician orders revealed the resident received Lactulose solution 10 grams/15 ml, with instruction to give 15 ml by mouth every 12 hours as needed for constipation and Senna-plus 8.6/50 milligrams 2 by mouth every day for constipation. Review of the electronic record bowel movement documentation revealed no bowel movement had been documented from 7/28/22 through 8/15/22. The resident was discharged to the hospital on 8/16/22. An interview was conducted with the Director of Nursing (DON) on 8/16/22 at approximately 3:57 PM. The DON stated that staff were expected to document whether or not the resident had a bowel movement every shift in the task menu. She stated nursing was to check the alerts in the electronic record daily to monitor bowel movements. 105148 Page 2 of 2