Inspection·February 5, 2021

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 record review and interview, the facility failed to ensure the accuracy of the Preadmission Screening for individuals with a mental disorder and/or an intellectual disability for four (Residents #14, #37, #94 and #41) of 38 sampled residents. Failure to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) could result in a resident's not receiving necessary health care services, which could contribute to a cognitive or physical decline in health status. Residents Affected - Few The findings include: 1. A record review for Resident #14 revealed he was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder and unspecified dementia without behavioral disturbance. His last readmission was on 10/13/2020, at which time he returned to the facility with a diagnosis of schizophrenia. Additional diagnoses for Resident #14 included anxiety disorder and senile degeneration. Further review of Resident #14's record revealed a PASRR screening dated 2/23/2017. The PASRR failed to identify the diagnoses of Serious Mental Illnesses (SMIs) and/or Intellectual Disability or Related Conditions (ID) for Resident #14. There was no record of a referral for/or a Level II assessment after the screening. 2. A record review for Resident #37 revealed that the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, cognitive/communication deficit, major depressive disorder, and hallucinations. Her last readmission was on 11/10/2019. Additional diagnoses documented for Resident #37 included schizophreniform disorder and anxiety disorder. Further review of Resident #37's record revealed a PASRR dated 8/27/2018. The PASRR identified the SMI diagnosis of anxiety disorder in section IA. There was no record of a referral for/or a Level II assessment after the screening. 3. A record review for Resident #94 revealed that the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, altered mental status, schizophrenia, and bipolar disorder. Additional diagnoses documented for Resident #94 included major depressive disorder. Further review of Resident #94's record revealed a PASRR dated 10/30/2020. The PASRR identified SMI diagnoses bipolar disorder and schizophrenia in section IA. There was no record of a referral for/or a Level II assessment after the screening. (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: 105756 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 105756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Hilliard 3756 W Third St Hilliard, FL 32046 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)