**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #24). The facility reported a census of 35 residents. Findings include: Resident #24's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included a diagnosis of bipolar disorder. Resident #24 received antipsychotic medications during the lookback period. The Care Plan Focus revised 9/5/24 reflected Resident #24 had a behavior problem, refused to be checked and changed when wet, he would seek out women, he would pace up and down the halls. The Care Plan Goal indicated Resident #24 wouldn't have a negative outcome from the behaviors. Resident #24's Medical Diagnosis reviewed on 12/11/24 included a diagnosis of bipolar disorder effective 10/2/23. Resident #24's clinical record review revealed a negative Level 1 PASRR screening completed 7/31/23. The Level 1 PASRR documented the mental health conditions for Resident #24 as depression and altered mental status. The clinical record lacked a Level II PASRR evaluation submission following the new mental health diagnosis of bipolar disorder effective 10/2/23. Resident #24's December 2024 Medication Administration Record (MAR) included an order started 6/11/24 for aripiprazole (antipsychotic) 5 milligrams (MG) 1 tablet by mouth 1 time a day related to bipolar disorder. On 12/11/24 at 8:54 AM, the Director of Nursing (DON) reported the facility didn't complete a Level II PASSR evaluation for Resident #24 because the new diagnosis of bipolar disorder became effective 10/2/23. During a follow-up interview on 12/11/24 at 10:00 AM, the DON acknowledged the facility didn't complete a Level II PASSR with Resident #24's diagnosis of bipolar disorder. The DON added the facility didn't have a policy or protocol regarding the completion of PASRRs as they followed the regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a significant change following admission to hospice care for 1 of 2 residents reviewed (Resident #5). The facility reported a census of 36 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] for Resident #5 documented a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severe cognitive impairment. The MDS documented the resident admitted to the facility 7/25/17 with the most recent reentry date of 6/10/22 from the hospital. The MDS documented the resident had diagnoses including diabetes mellitus, non-Alzheimer's dementia and malnutrition. The MDS further documented the resident received hospice care in the last 14 days. The Physician Orders dated 7/7/22 for Resident #5 documented an order for hospice of choice evaluation and admit if eligible. The Care Plan revised 7/7/22 revealed Resident #5 had chosen to receive hospice care. Review of facility policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current Omnibus Budget Reconciliation Act (OBRA) regulations governing resident assessments and is outlined in the MDS Resident Assessment Instument (RAI) manual. Clinical record review revealed a significant change had not been completed following the admission to hospice care. During an interview 11/10/22 at 11:52 AM, the Director of Nursing (DON) acknowledged a significant change had not been completed following Resident #5's admission to hospice care.