Health inspection·August 1, 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 observation, interview, record review, and policy review, the facility failed to ensure accuracy of Preadmission Screening and Resident Review (PASRR) forms for 1 of 1 residents sampled for PASRR review. (Resident #1) Residents Affected - Few The findings included: On 7/29/24, a review of the PASRR from dated 1/13/23 for Resident #1 was conducted. Section A of the form indicated that Resident #1 had a history of Bipolar Disorder and Schizophrenia. The form had no additional information regarding functional criteria, services, or basis for findings. The PASRR form indicated that Resident#1's admission was not a provisional admission. Section IV of the form indicated that Resident #1 had no diagnosis or suspicion of serious mental illness or mental disability and a level II PASRR was not required. The form was signed by a hospital staff member and dated 1/13/23. On 7/30/24, a review of Resident #1's records was conducted. The diagnosis list of Resident #1 revealed that she was admitted on [DATE] with an admitting diagnosis of paranoid schizophrenia. Bipolar Disorder was also added to the diagnosis list on 1/17/2023. A review of the psychiatric evaluation of Resident #1, dated 7/25/24, indicated that the resident had an ongoing history of paranoid schizophrenia and bipolar disorder with a depressed mood. Resident #1 had been prescribed psychotropic medications for the management of paranoid schizophrenia and bipolar disorder. A review of the Care Plan revealed that Resident #1 had a diagnosis of paranoid schizophrenia with periods of agitation and yelling out. The care plan indicated that Resident #1 can become combative and refuse care at times. The goal listed on the care plan was that she would have no behaviors that prevent the delivery of care through the next review date. The review of the Social Service Quarterly Assessment note dated 7/10/24 indicated that the resident experienced delirium in the forms of inattention and disorganized thinking. The entry indicated that Resident #1 often had difficulty tracking conversations and derailment was evidenced, many questions were answered tangentially as she provided irrelevant responses to questions. Her speech is sometimes presented as gibberish. The note indicated that Resident #1's legal guardian was contacted. Current psychotropic medications and results of recent screenings for depression were reviewed with the guardian. On 08/01/24 at approximately 9:29 AM, an interview was conducted with the Director of Admissions and Marketing (DOAM). She was asked to review the PASRR form, diagnosis list, and record Resident #1. Page 1 of 2 105328 105328 08/01/2024 Santa Rosa Center for Rehabilitation and Healing 5386 Broad St Milton, FL 32570

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DOAM verified that Resident #1 was admitted as a long-term admission and the PASRR dated 1/13/23 was that the most recent. The DOAM explained that she relies on the admitting hospital to let her know her if a PASRR level II is indicated. She was asked to describe the process for review of PASRR forms received from the hospital for accuracy. The DOAM explained that she would consult the Director of Nursing (DON) for any questions regarding PASRR screenings for newly admitted residents. She indicated that she has not had to request a resident review/evaluation request for any resident since starting in the position in August 2023. A copy of the facility policy for PASRR forms was requested. On 8/1/24 at approximately 9:58 AM, an interview was conducted with the Regional Nurse Consultant (RNC) regarding the PASRR for Resident #1. She explained that PASRR forms should be corrected if an error is identified. New admissions are reviewed in a clinical meeting. If a PASRR level II is indicated, the DON would complete and submit a PASRR review request. The RNC was asked if Resident #1 should have had a PASRR level II requested. She indicated that the PASRR form would be corrected. 105328 Page 2 of 2