Health inspection·August 15, 2024

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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105423 If continuation sheet Page 2 of 3 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 105423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257 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 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. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105423 If continuation sheet Page 3 of 3