Health inspection·May 15, 2025

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 observations, interviews and record review the facility failed to ensure residents received an accurate Preadmission Screening and Resident Review (PASRR) Level I screening and a Level II screening for one (Resident 91) out of two residents reviewed. Resident 91 did not receive a PASSAR Level II after admission to the facility. There were a total of 139 residents residing in the facility at the time of this survey. Residents Affected - Few The findings included: Record review of the Preadmission Screening and Resident Review (PASSR) Policy and Procedure (reviewed January 2025) documented: Policy-The facility ensures that a all residents admitted to the facility has PASSR Level I done prior to admission to facility or Level II as indicated by resident's condition and diagnosis of resident. Procedure: 1) Prior to admission, the admission department including nurse navigator must ensure that hospital or another nursing home facility has completed PASSR Level I for new residents prior to admittance to facility and 2) Upon receipt of PASSR I from hospital or another nursing home, facility will review PASSR Level by DON (Director of Nursing) or designee. If PASSR Level I indicates that a resident has serious mental illness and PASSR Level I indicates that a PASSR Level II is needed, facility must request from hospital or another nursing home, a PASSR Level II prior to admission to facility. Observation of Resident number 91 on 5/14/2025 at 7:52 AM revealed the resident sitting up in bed, eating breakfast with the television on. Review of the Demographic Face Sheet for Resident number 91 documented the resident was admitted on [DATE] with a diagnosis of acute respiratory failure, bipolar disorder, major depressive disorder, insomnia, dementia and schizophrenia. Review of the Minimum Data Set (MDS) Annual Assessment for Resident number 91 dated 2/27/2025 documented the resident's Mental Status (BIMS) Summary Score was not scored indicating severe cognitive impairment, the resident required substantial/maximal to dependent assistance for ADLs (Activities Daily Living) and Preadmission Screening and Resident Review (PASRR), the resident was not evaluated for a Level II PASSR and was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The resident was not evaluated for PASRR Level II. Review of the Physician's Order Sheet (POS) for March 2025, April 2025 and May 2025 documented the resident received Mirtazapine Tablet 7.5 MG (milligrams) give 1 tablet by mouth at bedtime related to major depressive disorder and Sertraline HCl (Hydrochloride) Oral Tablet 25 MG give 1 tablet by mouth in the morning related to major depressive disorder. (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 7 Event ID: 106021 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 106021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130 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)