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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105148
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
105148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/18/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Emerald Shores
626 N Tyndall Pkwy
Callaway, FL 32404
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105148
If continuation sheet
Page 2 of 2
