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. (continued on next page) 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: 105328 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 105328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Rosa Center for Rehabilitation and Healing 5386 Broad St Milton, FL 32570 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)