Health inspection·August 15, 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 observations, interviews, record reviews, and facility policy and procedure review, the facility failed to provide two (Residents #82 and #62) of four residents with diagnoses of a serious mental illness (SMI) with Level II preadmission screening and resident review (PASRR) screenings as required, from a total survey sample of 34 residents. Residents Affected - Few The findings include: 1. A review of Resident #82's medical record revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, unspecified dementia, bipolar disorder, insomnia, other specified depressive episodes, and Pseudobulbar affect. A review of her annual minimum data set (MDS) assessment, dated 6/10/24, revealed that in Section A1500, the resident had not been evaluated by Level II PASRR and had no serious mental illness (SMI) or intellectual disability (ID). Section I of the assessment indicated a diagnosis of non-Alzheimer's dementia, anxiety disorder, depression, bipolar disease, and Pseudobulbar affect. The resident received antipsychotic, antianxiety, and antidepressant medications during the look-back period. A review of the resident's physician's orders revealed the following: Resident received Abilify 5 mg (milligrams), take 0.5 tablet at bedtime for diagnosis: Bipolar Disorder (4/2/24) Ativan (antianxiety medication) 0.5 mg by mouth, Indication: yelling out (4/16/24) Nudexta 20 - 10 mg by mouth twice daily, Indication: Pseudobulbar affect (11/13/23) Remeron 15 mg by mouth, give 7.5 mg daily for decreased appetite (6/27/24) Further review of the resident's record revealed a Level 1 PASRR dated 6/9/20, completed by the acute care hospital prior to the resident's nursing home admission. This PASRR triggered a Level II PASRR for serious mental illness. A Level II PASRR was unavailable in the resident's electronic medical record (EMR). On 8/13/24 at 12:36 PM, an interview was conducted with the Regional Nurse Consultant (RNC) who was providing documents unavailable in the EMR to the surveyor. She was asked to review Resident #82's Level 1 PASRR results to verify that the Level 1 PASRR triggered a Level II PASRR. She was asked to provide the Level II PASRR that was indicated by the Level 1 PASRR dated 6/9/20. She provided the Page 1 of 3 105423 105423 08/15/2024 Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident Review (RR) evaluation request, completed by the acute care hospital on 6/9/20. She said she did not know why a Level II PASRR was not completed at that time; it was prior to her employment with the company. A review of the facility's policy titled PASARR, 2001 MED-PASS, Inc. (Revised March 2019, reviewed 08/2021, 06/2023, 01/2024) revealed: 1b. If the Level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASSAR representative for the Level II (evaluation and determination) screening process. 2. A review of Resident #62's medical record on 8/13/24 at 11:04 AM, revealed diagnoses of dementia and major depressive disorder dated 10/13/21, that were not identified on the resident's PASRR dated 2/3/18. A review of Resident #62's medicalrecord revealed an readmission date of 12/16/22 and an initial admission date of 2/16/18. Her diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, other specified anxiety disorders, paranoid schizophrenia, and insomnia. Resident #62's active physician's orders included Buspirone 10 mg (milligrams) for anxiety two times daily at 6:00 AM and 6:00 PM, started on 5/23/23; Citalopram 10 mg via gastric tube once a day at 6:00 AM for depression, starting on 5/11/23; and Seroquel (quetiapine - antipsychotic) 25 mg via gastric tube at bedtime at 9:00 PM for depression, started on 6/13/24. A review of the MDS assessment, dated 7/12/24, revealed that the resident was readmitted from an acute care hospital. Section A1550 related to PASRR was blank. The resident's brief interview for mental status (BIMS) was completed by staff and indicated that the resident's cognitive skills for daily decision-making were moderately impaired - decisions poor, cues/supervision required. An interview was conducted with the Social Services Director (SSD) on 8/15/24 at 12:09 PM. She stated nursing assisted her with completing the resident assessments to identify a history of depression. Assessments were completed as needed and quarterly. If signs of depression were identified, the resident would be referred to the psychiatric team. A resident identified as having a newly evident or possible mental disorders (MD), ID, or related condition after admission, would be assessed to ensure they had a disorder. Residents found to have a disorder were reported and referred to determine whether a PASRR Level II was needed. The SSD stated she was responsible for ensuring that a referral was sent to the appropriate state-designated authority. An interview was conducted with the Director of Nursing (DON) on 8/15/24 at 12:25 PM. She stated the facility's process for identifying residents with a possible MD, ID, or related condition prior to admission, was to consult with the Interdisciplinary Team and refer to psychiatric services for evaluation. Residents with newly evident or possible serious mental conditions, after admission to the facility, hospital documentation as well as observations for signs or symptoms related to behaviors were reviewed and evaluated. If issues or concerns were identified, the physician was contacted and a psychiatric consult and review of medications was completed. The SSD completed the PASRR and worked with the Administrator to refer the resident to the appropriate state-designated authority. The process was to collaborate with the Interdisciplinary Team, stabilize the resident, and/or [NAME] Act the resident, if necessary, to ensure other residents were kept safe. When she was asked if a PASRR Level II was required for Resident #62, the DON confirmed that Resident #62 required a PASRR Level II screening. 105423 Page 2 of 3 105423 08/15/2024 Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled PASARR (revised date 03/2019), revealed: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. the facility conducts a level l PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. if the level l screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level ll (evaluation and determination) screening process. 1. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. 2. The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs. And whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified. . 105423 Page 3 of 3