Inspection·June 15, 2023

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 interview and record review, the facility failed to obtain a Level II screening for 3 of 6 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Residents #25, #37, and #96) Residents Affected - Few The findings include: Resident #96 A review of the PASARR form for Resident #96 (admitted on [DATE]) noted an identified diagnosis of Anxiety Disorder and a diagnosis of dementia. Per the PASARR form, the combination of a Serious Mental Disorder (SMI) diagnosis and Dementia or neurocognitive disorder would trigger the requirement for a Level II review. A review of the admission Diagnosis in the medical record noted a diagnosis of Major Depressive Disorder and Unspecified Dementia, Unspecified Severity with Psychotic Disturbance. A review of the Care Plan for Resident #96 noted that the resident was care planned for antipsychotic therapy for diagnosis of dementia with psychotic features, auditory and visual hallucinations, and antidepressant usage. A review of the physician's progress note dated 6/13/2023 noted a medical history of dementia and depression with a hospital admission related to auditory and visual hallucinations. Past medical histories noted diagnoses of Unspecified dementia of unspecified severity with psychotic disturbance and Major Depressive Disorder. Medications prescribed included Sertraline HCL and Donepezil, both psychotropic medications. A review of the admission Minimum Data Set (MDS) dated [DATE] noted that section A1500 did not acknowledge a Serious Mental Illness and Section A1550 did not acknowledge the submission of a Level II PASARR screening. A review of the complete medical record could not locate a Level II PASARR for resident #96. On 06/15/23 at approximately 11:54 AM, the Director of Nursing (DON) was asked what the PASARR process is for completion and validation. She stated they all residents should come with a PASARR prior to admission. In some cases, the facility will get them done. The DON was advised that a Level II PASARR could not be located on Resident #96 even though the her PASARR form triggered for a Level II. The DON acknowledged that a Level II PASARR was not done. Resident #25 (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 4 Event ID: 105445 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 105445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at University Hills 10040 Hillview Road Pensacola, FL 32514 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)