Inspection·June 10, 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** Residents Affected - Few Based on interviews and record reviews, the facility failed to ensure the completion of pre-admission screening for individuals with a mental disorder and individuals with an intellectual disability for one (Resident #39) of 27 residents in the sample. The findings include: A medical record review for Resident #39 indicated he was admitted to the facility on [DATE]. His diagnoses included intermittent, explosive disorder, bipolar disorder and schizophrenia. His physician's orders revealed orders for Paroxetine 30 milligrams (Mg) by mouth (PO) every day (QD) for depression, and Risperidone 1 mg two times a day (BID) for bipolar disorder. A 5-day admission Minimum Data Set (MDS) assessment revealed the resident had not been evaluated via Level II Pre-admission Screening and Resident Review (PASRR) to determine serious mental illness and/or mental retardation or related condition. Further review indicated that Resident #39 had a Brief Interview for Mental Status score (BIMS) of 07 out of 15 possible points, indicating severe cognitive impairment. The resident also reported feeling depressed or hopeless, feeling tired and having little energy for 2- 6 days, and received antispychotic and antidepressant medication for 7 days and antianxiety medication for 3 days during the look back period. His care plan indicated that he was on antianxiety, antidepressant and psychotropic medications related to anxiety, depression and bipolar disorders respectively. A review of the Level I PASRR dated 4/19/2021, Section 1, revealed the following: Schizophrenia onset prior to [AGE] years of age. Currently receiving services for mental illness (MI), and Intellectual disability (ID). Section II 1. indicated that Resident #39 had or may have had a disorder in functional limitation in major life activities that would otherwise be appropriate for the individual's developmental stage. Previously received services for MI and ID. Section IV was incomplete. (Copy obtained) A review of the Hospital Discharge summary dated [DATE], revealed: Past medical history indicated mental deficiency, schizophrenia, and intermittent explosive disorder. Resident's father described him as never having issues with depression, always just wild due to his schizophrenia and requiring seroquel, risperdal, and carbamazepine, and never on an anti-depressant. During an interview on 06/09/2021 at 12:35 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked about Resident #39's Level II PASRR. They confirmed that the level II PASRR was not completed. They also stated that Resident #39 lived in a group home owned by his parents prior to admission. When asked whether the resident had received a psychiatric evaluation, they stated, No. They added that the facility did not have a psychiatric physician and residents were (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: 105820 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 105820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE University Crossing 6210 Beach Blvd Jacksonville, FL 32216 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)