**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Mental Wellness Services, the facility failed to perform a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 41 sampled residents (R) (R108) reviewed. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: A review of the facility policy titled Mental Wellness Community last reviewed 12/27/2024 revealed under Guideline: Patients living on the community should have appropriate level 1's completed as required to determine whether a new level 2 is needed. For those patients whose level 2 evaluation has determined that they have a serious mental illness or mental retardation, the level 2 recommendations are followed. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] Section A (Identification Information) revealed R108 had not been evaluated for level II PASRR. A further review revealed R108 had a Brief Interview for Mental Status (BIMS) from Section C (Cognitive Patterns) score of 14, indicating little or no cognitive deficit, and a diagnosis from Section I (Active Diagnoses) of Manic Depression (bipolar disease). A review of the electronic medical record (EMR) revealed that R108 had diagnoses that included but not limited to bipolar disorder. Further review revealed R108's level I PASRR dated 11/25/2024 reflected that R108 did not have bipolar disorder. A review of R108's physician's (MD) orders revealed an order for oxcarbazepine 300 mg milligrams) two tablets, dated 11/28/2024, to be administered by mouth twice per day for the treatment of bipolar disorder, Seroquel 300 mg 0.5 tablet, ordered 12/12/2024, to be administered by mouth at bedtime every day for bipolar disorder, and venlafaxine ER (extended release) 150 mg, dated 11/27/2024, to be administered by mouth every day for bipolar disorder. During an interview with the Director of Nursing (DON) on 4/13/2024 at 9:20 am, she stated that the Social Worker (SW) was responsible for auditing the PASARRs in the facility, but the SW overlooked R108's level II PASRR. The DON acknowledged that R108 did have bipolar disorder and should have been evaluated based on her diagnosis. The DON added that the SW was not in the facility and was unavailable for an interview.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Transmission-Based Precautions (Contact, Enhanced Barrier, Droplet, Airborne) and Hand Hygiene, the facility failed to ensure infection control processes were followed during a dressing change for one of 13 residents (R) (R12) on enhanced barrier precautions (EBP). This deficient practice created the potential for the spread of infections in the facility. Findings include: Review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier, Droplet, Airborne), dated 12/27/2024, revealed the Enhanced Barrier Precautions (EBP), section included, Enhanced Barrier Precautions are indicated for patients with any of the following: . Wounds and indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO [multi drug resistant organism]. Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high contact activities that promote opportunities for transfer of MDROs to staff hands and clothing, . Examples of high contact patient care activities requiring gown and glove use for Enhanced Barrier Precautions include . Device care or use: .feeding tube . Review of the facility's policy titled, Hand Hygiene, dated 12/27/2024, revealed the Purpose section stated, Hand hygiene is the single most important means of preventing the spread of infections. The use of gloves does not replace hand washing. The Guideline section included, .Associates should use alcohol based hand rub or wash hands with soap and water for the following indications: . Immediately after glove removal. Gloves should not be used as a substitute for hand hygiene. Perform hand hygiene immediately after removing gloves. Review of R12's quarterly Minimum Data Set (MDS) assessment, dated 3/5/2025, revealed Section K (Swallowing Disorders) documented R12 had a feeding tube. Review of R12's care plan dated 3/14/2025 revealed a care area of skin breakdown risk due to a gastrostomy tube (G-tube) [a tube inserted through the abdominal wall directly into the stomach] site dressing with intervention to change the dressing as ordered. Review of R12's physician's orders revealed an order dated 11/8/2024 to clean the G-tube site once per day and apply a drain sponge (a type of dressing). Observation of G-tube site dressing change on 4/12/2025 at 10:00 am revealed Licensed Practical Nurse (LPN) AA entered R12's room to perform the procedure with the supplies in her hands. After providing privacy, she washed her hands, donned (put on) gloves, removed the G-tube site dressing, discarded the dressing in a trash can, cleaned the site per the physician's order, discarded the cleaning material, doffed (took off) her gloves, donned clean gloves, placed the dressing on the site, doffed gloves, and performed hand hygiene. She did not wear a gown or perform hand hygiene between glove changes during the procedure. Observation of R12's room revealed EBP signage on the wall above the head of the bed instructing staff to wear a gown and gloves when providing high-contact care to the resident. Further observation revealed gloves and an alcohol-based hand rub (ABHR) dispenser on the wall inside the room. In an interview on 4/12/2025 at 10:15 am, LPN AA confirmed she did not wear a gown for the procedure or perform hand hygiene between glove changes. She stated she was aware R12 was on EBP due to the G-tube and should have worn a gown for the procedure. She further stated she should have performed hand hygiene when changing gloves, and she was nervous and forgot to wear the gown and perform hand hygiene between glove changes. She stated that PPE was available on the supply carts in the hallways. In an interview on 4/12/2025 at 2:00 pm, the Director of Nursing (DON) stated the nurses should wear gloves and a gown when providing G-tube site dressing changes, and hand hygiene should be performed between glove changes and when going from dirty to clean steps during dressing changes. She further stated that the infection control process should be followed to prevent the spread of infections.