Inspection·November 7, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to refer a resident with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 3 residents reviewed for PASARR, of a total sample of 45 residents, (#72). Findings: Resident # 72's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's and diabetes mellitus, bipolar disorder, depression, schizoaffective disorder, and anxiety. The MDS Significant Change assessment with reference date 8/27/24 revealed resident #72 had severe cognitive impairment. The document indicated her active diagnoses included anxiety disorder, depression (other than bipolar), and schizophrenia. Resident #72's medical record revealed diagnoses of anxiety disorder and bipolar disorder with an onset date of 3/31/24 and schizoaffective disorder with an onset date of 7/23/24. The record contained a Level I PASARR screening form dated 3/11/23 which indicated resident #72 had an Mental Illness (MI) or suspected MI. The record did not contain a Level ll PASARR screening form. On 11/07/24 at 1:04 PM, the Social Services Director (SSD) stated that a new admission from the hospital should have a Level I PASARR screening completed by the hospital before admission. She noted the clinical team reviews the PASARRs upon admission. She said the Director of Nursing completed a new PASARR if it was inaccurate or if the resident received an MI diagnosis after admission. On 11/07/24 at 1:35 PM, the Assistant Director of Nursing (ADON) stated that the PASARR was reviewed and updated by the Director of Nursing (DON). The ADON acknowledged resident #72's level I PASARR was inaccurate and needed updating. The facility's policy and procedure for Pre-admission Screening for Serious Mental Illness (SMI) and Intellectually Disabled (ID) Individuals (PASRR), revised July 2021, read, If it is learned after admission that a Serious Mental Illness (SMI) or Intellectually Disabled (ID) Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 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 3 Event ID: 105577 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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)