**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code two Minimum Data Set (MDS) assessments related to an antipsychotic medication for 1 of 1 residents reviewed for suicidal attempts. (Resident B) Findings include: The clinical record of Resident B was reviewed on 5-1-24 at 9:52 a.m. His diagnoses included, but were not limited to, anxiety, depression, nightmare disorder and suicidal ideation. His most recent MDS assessment, a quarterly assessment dated [DATE], indicated he received antipsychotic medications in Section N0415A, related to medications ordered for the resident. However in Section N0450A, the MDS assessment was coded to reflect he did not receive antipsychotic medications, thus negating the use of a gradual drug reduction information for the use of this type of medication. In the prior MDS, an annual assessment, dated 11-17-23, this information was identified in the same manner. In an interview with the MDS Coordinator on 5-1-24 at 11:34 a.m., she indicated it appeared as if she had coded the information for the use of an anti-psychotic incorrectly. She indicated the clinical record indicated he had received Zyprexa, an antipsychotic medication, during the look-back period period of 7 days for each of the MDS assessments. A review of Resident B's medication administration record (MAR) for November, 2023, indicated he had received Zyprexa 2.5 milligrams (mg) twice daily from 11-15-23 through 11-30-23. A review of the February, 2024 MAR indicated he had received Zyprexa 2.5 mg twice daily for 2-1-24 through 2-29-24. In an interview with the Executive Director on 5-1-24 at 2:30 p.m., she indicated the facility does not have a specific policy or procedure related to the MDS assessment process, but uses the current RAI (Resident Assessment Instrument) Manual for reference to any MDS assessments. The Centers for Medicare and Medicaid Long-Term Care Facilities Resident Assessment Instrument 3.0 User's Manual, version 1.1811, October, 2023, indicates in Section N, Medications, for Section N0415, High Risk Drug Classes: Use and Indication, the appropriate high-risk medications should be checked, such as antipsychotic medications have been administered in the 7-day look back period. Residents taking medications in these medication categories and pharmacological classes are at risk of side effects that can adversely affect health, safety, and quality of life. In Section N, Section N0450A, Antipsychotic Medication Review, this portion requests, Did the resident receive antipsychotic medications since admission/entry or readmission or the prior OBRA assessment, whichever is more recent? The response choices for N0450A provided for selections of yes, or no. This Federal tag relates to Complaint IN00432528. 3.1-37(a) 3.1-37(c)(13)

Based on observation, interview and record review the facility failed to provide fresh ice water for 1 of 2 residents reviewed for hydration (Resident 4). Finding include: During an observation and interview on 9/27/23 at 1:52 p.m., Resident 4 indicated she had to ask if she wanted ice water, she hasn't gotten fresh ice water since last night. The facility staff were observed passing out fresh ice water and went by Resident 4's room without providing fresh water. During an observation on 9/27/23 at 2:40 p.m., Resident 4 continues to have a half cup of warm water. The resident indicated her and her roommate had not received fresh water since last night. During an observation on 9/28/23 at 9:45 a.m., Resident 4 continues with the same half cup of warm water with no fresh ice water available. During an observation on 9/28/23 at 11:00 a.m., Resident 4 continues with a cup of warm water with no fresh ice water available. Resident 4 was laying in bed with her eyes closed. During an interview and observation on 9/28/23 at 1:42 p.m., Resident 4 had two cups of warm water. The resident indicated she frequently did not receive fresh ice water, she often had to request ice water from staff. Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnoses included, but were not limited to, age related physical debility, osteoarthritis, pain in right/left knee atrial fibrillation, hypertension, urinary tract infection, gout, anxiety and major depressive disorder. The plan of care for Resident 4, dated 10/18/22, indicated the resident was at risk for dehydration related to diuretic medication use. The interventions were monitor weight and vital signs, observe for increased signs of edema and report any changes to the physician. The Quarterly Minimum Data (MDS) assessment for Resident 4, dated 7/20/23, indicated the resident was cognitively intact for daily decision. The resident was consistent and reasonable. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., indicated the facility protocol for providing residents with fresh ice water was it was passed first thing in the morning and in the evening. The facility also had a drink cart that passed out fluids twice a day. The DON indicated it was nursing's responsibility to ensure Resident 4 had fresh ice water. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's privacy curtain was wide enough to provide full visual privacy. This affected 1 of 1 resident reviewed. (Resident 32) Findings include: On 9/27/23, at 11:11 a.m., Resident 32's curtain, between her bed and her roommate's bed, was observed and did not extend from the wall at the head of her bed to the wall past the foot of her bed. The area from the foot of her bed to the wall past the foot of her bed was left exposed for approximately 4 feet. The track on the ceiling, that the curtain was hung from, extended from the wall at the head of her bed to the wall that went past the foot of her bed. There were 10 empty curtain hooks in the curtain track. Resident 32 indicated that anyone could see her in her bed if they walked into her room because the curtain didn't go down far enough. On 9/28/23, at 2:45 p.m., Resident 32 was in bed, with her eyes closed, and the curtain between the beds was not wide enough to extend from wall to wall for privacy. Resident 32's record was reviewed, on 9/28/23, at 11:16 a.m. and indicated diagnoses, that included, but were not limited to, right knee contracture, type 2 diabetes mellitus, generalized muscle weakness, and difficulty in walking. A quarterly Minimum Data Set assessment, dated 8/16/23, indicated Resident 32 was cognitively intact. On 9/29/23, at 11:47 a.m., Resident 32 was in her room, seated in a wheelchair, and the curtain was observed with the Administrator. The Administrator indicated the curtain should be wide enough to go to the wall. A Policy for Dignity was provided by the Administrator, on 9/29/23, at 1:10 p.m., and included, but was not limited to .Privacy .4.) Staff will provide privacy for residents during any personal care and/or treatment. The privacy curtain must be pulled anytime that the resident needs to have privacy. Examples include but are not limited to bathing, showers, and so on 3.1-3(p)

Based on interview and record reviewed, the facility failed to accurate code six-month prognosis and hospice services (Resident 12) and medications (Resident 16) for 2 of residents reviewed for Minimum Data Set (MDS) accuracy. Findings include: 1. The clinical record for Resident 12 was reviewed on 9/29/2023 at 11:05 a.m. The medical diagnosis included respiratory failure with hypoxia. A Quarterly MDS assessment, dated got 6/28/2023, indicated that Resident 12 did not have a six-month or less prognosis and did not receive hospice services. A Quarterly MDS assessment, dated for 9/28/2023, indicated that Resident 12 did not have a six-month or less prognosis. A physician order, dated 5/6/2021, indicated Resident 12 received hospice services. A hospice recertification, dated 3/19/2023, indicated Resident 12 has a six month or less prognosis if disease runs its normal course and was recertified for hospice services. 2. The clinical record for Resident 16 was reviewed on 9/29/2023 at 10:55 a.m. The medical diagnosis included chronic obstructive pulmonary disease. A Quarterly MDS assessment, dated 7/17/2023, indicated that Resident 16 received seven days of anticoagulation medication. The medication administration record for Resident 16 for July 2023, indicated that Resident 16 did not receive anticoagulation medication. An interview with the MDS Coordination on 9/29/2023 at 11:02 a.m. indicated that she could not find where Resident 16 used anticoagulation medications and verified that Resident 12 was on hospice services during the aforementioned quarterly assessments. She indicated she would be modifying the assessments discussed and that they code to the MDS Resident Assessment Instrument.

Based on interview and record review the facility failed to develop a plan of care for a resident with recurrent Urinary Tract Infections (UTI) for 1 of 1 resident reviewed for UTI (Resident 4). Finding include: Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnosis included, but were not limited to, chronic Urinary Tract Infection (UTI). The physician order for Resident 4, dated 7/21/23, indicated the resident was ordered to be seen by the urologist for recurrent UTI's. The physician order for Resident 4, dated 8/16/23, indicated the resident was ordered keflex (antibiotic) 250 milligrams (mg) indefinitely for recurrent UTI's. The urology report for Resident 4, dated 9/18/23, indicated the resident was being seen for recurrent UTI's. During an interview with Resident 4 on 9/28/23 at 1:42 p.m., indicated she had a long history of UTI's. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., verified Resident 4 did not have a plan of care in place for UTI's. The DON indicated it was the responsibility of the Minimum Data Set (MDS) Coordinator in develop the plan of care. The care plan policy provided by the Administrator on 9/29/23 at 10:50 a.m., indicated the facility Interdisciplinary team in conjunction with the resident, resident's family as appropriate along with a hands on caregiver, such as a certified nursing assistant will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well being attainable for the resident. 3.1-35(a)

Based on observation, interview and record review the facility failed to assess and monitor bilateral feet edema (swelling) for 1 of 1 resident reviewed for edema (Resident 4). Finding include: During an observation on 9/27/23 at 2:01 p.m., Resident 4 was sitting in a chair, her bilateral feet were swollen. During an observation and interview with Resident 4 on 9/28/23 at 1:42 p.m., the resident was laying in bed, her bilateral feet were swollen. The resident indicated her feet did swell often. The resident indicated nursing had not assessed her feet edema. Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnoses included, but were not limited to, age related physical debility, osteoarthritis, pain in right/left knee atrial fibrillation, hypertension, urinary tract infection, gout, anxiety and major depressive disorder. The plan of care for Resident 4, dated 10/18/22, indicated the resident was at risk for dehydration related to diuretic medication use. The intervention included, but were not limited to, observe for increased signs of edema and report any changes to the physician. The plan of care for Resident 4, dated 10/18/22, indicated the resident had a diagnosis of atrial fibrillation. The intervention included, but were not limited to, observe for signs and symptoms of edema. The Quarterly Minimum Data (MDS) assessment for Resident 4, dated 7/20/23, indicated the resident was cognitively intact for daily decision. The resident was consistent and reasonable. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., indicated the expectation of the facility was nursing would be assessing and monitoring Resident 4's bilateral feet edema. The DON indicated she could not find an assessment/monitoring of the resident's edema and would continue looking for it. During an interview the DON on 9/29/23 at 11:15 a.m., indicated she was not able to find an assessment from nursing for Resident 4's bilateral feet swelling. The DON indicated there was a physician order now to monitor the edema every shift now. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents reviewed for respiratory and other health-related conditions had timely and accurate assessments conducted in order to develop care plans that accurately reflect the resident's care and service needs. (Resident 41) Findings include: The clinical record of Resident 41 was reviewed on 8-19-22 at 2:35 p.m. His diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease or lung disease), obstructive sleep apnea, diabetes and heart failure. His admission Minimum Data Set (MDS) assessment, dated 7-17-22, indicated he was cognitively intact and indicated he received supplemental oxygen therapy, but did not indicate he utilized CPAP therapy. In an observation and interview of Resident 41 on 8-22-22 at 11:25 a.m., he was observed wearing supplemental oxygen via a nasal cannula with the rate at two liters per minute, with his respirations nonlabored. A CPAP machine was observed located on his bedside table. In an interview at this time, Resident 41 indicated he used the oxygen during the day and at night time, he uses the oxygen plus his CPAP. He indicated he has not had oxygen saturation levels checked daily by facility staff, as it had been occurring once daily or once every other day or sometimes less often. I figured they would check on [my] oxygen level at least once or twice a day. I would really like them to check it at least once a day. He indicated he brought the CPAP machine from home upon admission and had obtained it from his insurance and medical provider. In review of Resident 41 documents that reflected the facility's documentation of his oxygen saturation levels, it indicated on his admission on [DATE], it was documented as 98% (percent). The next documentation of his oxygen saturation was not dated until 7-28-22, 15 days later. A review of Resident 41's physician orders for July and August, 2022, provided by the Administrator on 8-22-22 at 1:40 p.m., failed to reflect any orders for the use of a CPAP machine or settings for it. An order for the continuous usage of oxygen at 2 liters per minute via nasal cannula was ordered upon admission, on 7-13-22. No orders were in place for checking of the oxygen saturation until 7-27-22. His orders did reflect he was ordered to receive medications and treatments that are used in persons for diabetes, cardiovascular health and respiratory medications. The initial admission nursing assessment, dated 7-13-22, indicated Resident 41 utilized oxygen therapy, with an oxygen saturation rate of 98% and had brought in a CPAP machine from home. The documentation failed to identify the settings for the CPAP machine. In an interview with the MDS Coordinator and the Social Services Designee (SSD) on 8-22-22 at 2:45 p.m., the SSD provided copy of Resident 41's initial care plan meeting with his family, dated 7-14-22. The initial care plan meeting indicated he utilized oxygen, but did not address the use of a CPAP machine. The MDS Coordinator indicated the current care plans did not address the concerns of his diagnoses of COPD, cardiac-related health issues and usage of supplemental oxygen and a CPAP machine. The MDS Coordinator indicated the current care plans did not reflect concerns with COPD, oxygen usage, CPAP usage, diabetes or heart health issues. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Oxygen Administration. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician .Residents with oxygen orders, routine and PRN, will have oxygen saturation levels measured by oximetry per physician order indicating clinical oxygen saturation to be maintained. Oxygen saturation will be checked and documented every shift to meet order specifications .Pulse Oximetry: Residents who have oxygen orders, whether scheduled or PRN will have oxygen saturation levels measured no less than daily. If MD orders states 'to maintain Sat' then oxygen saturation will be checked and documented every shift. MD will be notified whenever titration is required to maintain a saturation, which indicate a change in condition. Lung sounds and assessment will be reported to the MD at that time. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Continuous Positive Airway Pressure (CPAP). This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, Purpose: To improve ventilation on patients with obstructive sleep apnea (OSA), airway obstruction and upper airway resistance .Guideline: CPAP therapy must have a written physician's order. The order must include the level of CPAP, FIO2, if needed, and humidifier, if needed. The patient should be assessed before and after therapy has been initiated for any hazards or adverse effects such as pneumothorax and gastric distension .Procedure: Verify physician's order .order must include the level of CPAP, e.g. 5 cm H2O .Set CPAP level according to the physician ordered level . On 8-22-22 at 3:12 p.m., the Administrator provided a copy of a policy and procedure, entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 9-18-18. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of the facility to ensure every resident has a Baseline Care Plan completed and implemented within 48 hours of admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed. The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan .Procedure: Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concerns. At a minimum, it will address initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations. Observations, interview(s) with the resident and/or representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT team . The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAA's . 3.1-31(a) 3.1-31(c)(1) 3.1-31(c)(2) 3.1-31(c)(3) 3.1-31(c)(4) 3.1-31(c)(6) 3.1-31(d)(1) 3.1-31(e)

Based on interview and record review, the facility failed to ensure a level 1 PASARR (preadmission screening and resident review) was conducted after admission to the facility and follow-up with the need for a level 2 PASARR for a resident with a mental disorder. (Resident 37) Findings include: Resident 37's record was reviewed on 8/19/22 at 2:44 p.m. and indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic autonomic neuropathy, memory deficit following non-traumatic subarachnoid hemorrhage, hemiplegia and hemiparesis, schizophrenia, depression, and anxiety. A Quarterly Minimum Data Set assessment, dated 7/12/22, indicated Resident 37 was moderately cognitively impaired, had moods but no behaviors, was totally dependent on staff for activities of daily living, had impairment on one side of both upper and lower extremities in functional limitation in range of motion, did not walk, used a wheelchair, and had diagnoses of schizophrenia, depression and anxiety. A care plan, dated 4/5/22, indicated: At risk for behavioral disturbances r/t (related to) dx (diagnosis): Schizophrenia. On Antipsychotic med. Goal: Will have no adverse reaction to antipsychotic meds daily tnr (through next review). Will have no episodes of behavior r/t dx: daily TNR. Interventions: Antipsychotic meds per order. Approach resident calmly & quietly. GDR (gradual dose reduction) per guidelines. Monitor for effectiveness of meds, and interventions. Notify MD, Family and IDT (Interdisciplinary Team) of change in behaviors. Observe for adverse reactions to antipsychotic med such as but not limited to: Observe for behaviors. Psych per order. A care plan dated 4/29/22, indicated a focus of: 'Resident has dx. (diagnosis) of Schizophrenia and paranoia. Goals: The resident will be monitored for EPS (extrapyramidal side effects i.e. inability to sit still, involuntary muscle contractions and involuntary facial movements) through next review date. The resident will be monitored for s/sx (signs/symptoms) of schizophrenia through the next review date. Interventions: AIMS (Abnormal Involuntary Movement Scale) upon admission and quarterly thereafter. GDR per schedule. MD notified of any delusions, hallucinations, increased paranoia, and changes in behavior. Meds as ordered. Psych evals as ordered. A document completed by Maximus, and Notice of PASRR Level I Screen Outcome, dated 9/21/20, indicated no PASARR level II was required. The document was completed at the facility Resident 37 had been admitted from. There was no current PASARR that was completed by the current facility. A policy for Ascend - PAS (Pre-admission Screening) and LOC (Level of Care) was provided by the Administrator on 8/24/22 at 1:30 p.m. The policy included, but was not limited to, Purpose: Based on the PAS and Level of Care (LOC) changes effective 7.1.16; the Division of Aging is using Assessment Pro to tract patients from hospitals/home to facility. This new procedure requires a detailed clinical assessment of the patients demanding nursing administration and the business office to work together to ensure timely payment from Medicaid. Procedure: 1. Level 1 - either by hospital or nursing facility PRIOR to admission .All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level 1 PASRR completed to screen for possible mental illness (MI), intellectual disability (id), developmental disability (DD), or related conditions .Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

2. The clinical record of Resident 41 was reviewed on 8-19-22 at 2:35 p.m. His diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease or lung disease), obstructive sleep apnea and heart failure. His admission Minimum Data Set (MDS) assessment, dated 7-17-22, indicated he was cognitively intact and indicated he received supplemental oxygen therapy, but did not indicate he utilized CPAP therapy. In an observation and interview of Resident 41 on 8-22-22 at 11:25 a.m., he was observed wearing supplemental oxygen via a nasal cannula with the rate at two liters per minute, with his respirations nonlabored. A CPAP machine was observed located on his bedside table. In an interview at this time, Resident 41 indicated he used the oxygen during the day and at night time, he uses the oxygen plus his CPAP. He indicated he has not had oxygen saturation levels checked daily by facility staff, as it had been occurring once daily or once every other day or sometimes less often. I figured they would check on [my] oxygen level at least once or twice a day. I would really like them to check it at least once a day. He indicated he brought the CPAP machine from home upon admission and had obtained it from his insurance and medical provider. A review of Resident 41's physician orders for July and August, 2022, provided by the Administrator on 8-22-22 at 1:40 p.m., failed to reflect any orders for the use of a CPAP machine or settings for it. An order for the continuous usage of oxygen at 2 liters per minute via nasal cannula was ordered upon admission, on 7-13-22. No orders were in place for checking of the oxygen saturation until 7-27-22. His medical diagnoses listed on the July and August, 2022 physician order summary for 7-1-22 to 7-31-22, included but were not limited to congestive heart failure, atherosclerotic heart disease, hypertension, unspecified heart failure, pure hpercholesterolemia, type 2 diabetes, obstructive sleep apnea, chronic obstructive pulmonary disease, and unspecified dependence on other enabling machines and devices. The initial admission nursing assessment, dated 7-13-22, indicated Resident 41 utilized oxygen therapy and had brought in a CPAP machine from home. The documentation failed to identify the settings for the CPAP machine. In an interview with the MDS Coordinator and the Social Services Designee (SSD) on 8-22-22 at 2:45 p.m., the SSD provided copy of Resident 41's initial care plan meeting with his family, dated 7-14-22. The initial care plan meeting indicated he utilized oxygen, but did not address the use of a CPAP machine. The MDS Coordinator indicated the current care plans did not address the concerns of his diagnoses of COPD, cardiac-related health issues and usage of supplemental oxygen and a CPAP machine. The MDS Coordinator indicated the current care plans did not reflect concerns with COPD, oxygen usage, CPAP usage, diabetes or heart health issues. On 8-22-22 at 3:12 p.m., the Administrator provided a copy of a policy and procedure, entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 9-18-18. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of the facility to ensure every resident has a Baseline Care Plan completed and implemented within 48 hours of admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed. The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan .Procedure: Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concerns. At a minimum, it will address initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations. Observations, interview(s) with the resident and/or representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT team . The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAA's . 3.1-35(a) 3.1-35(b) 3.1-35(c)(1) 3.1-35(d)(1) 3.1-35(d)(2) 3.1-35(d)(2)(A) 3.1-35(d)(2)(B) Based on observation, interview, and record review, the facility failed to develop a care plan for a resident who received a cholesterol lowering medication (Resident 23), and failed to develop a care plan for a resident who used oxygen, a continuous positive airway pressure machine (CPAP), and had heart disease and diabetes (Resident H). This affected 2 of 20 residents reviewed for care plans. 1. Resident 23's record was reviewed on 8/19/22 at 1:12 p.m. and indicated he had diagnoses that included, but were not limited to, hypercholesterolemia (high blood fats). A physician's order, with a start date of 6/16/22, indicated the order for Atorvastatin calcium (lowers cholesterol/blood fats) 80 milligrams, one by mouth at bedtime for pure hypercholesterolemia. There was no care plan in the resident's record to address the use of Atorvastatin. On 8/24/22 at 1:30 p.m., the Administrator provided a care plan for increased lipid levels associated with hypercholesterolemia, dated 8/22/22. The Administrator indicated the care plan had just been added.

3. The clinical record of Resident H was reviewed on 8-19-22 at 11:22 a.m. Her diagnoses included, but were not limited to, current positive Covid-19 status and in transmission-based precautions (isolation), unspecified dementia without behavioral disturbance, polyneuropathy, muscle wasting and atrophy. Her most recent Minimum Data Set assessment, dated 6-24-22, indicated she was cognitively impaired, required extensive assistance of one person for personal hygiene activities, such as nail care, and was dependent for assistance with bathing of one person. A review of CNA Shower Checklist forms, dated 7-13-22 through 8-17-22, indicated Resident H had received her preferred bed bathes. The document indicated she had received nail care of nails clipped and cleaned on 7-16-22, 7-22-22, 7-23-22, 7-30-22 and 8-6-22. The document indicated Resident H had her nails clipped, but not cleaned on 7-13-22, 8-13-22. The document indicated on 7-27-22, her nails were cleaned, but did not need clipping. The document indicated Resident H did not have her nails clipped or cleaned on 8-17-22. In observations of Resident H on 8-18-22 at 2:12 p.m., 8-19-22 at 11:00 a.m., and 8-19-22 at 3:15 p.m., all of her fingernails appeared long and discolored with a yellow cast to them with a large amount of dark to medium brown-colored debris under each nail. In an interview with Resident H on 8-18-22 at 2:12 p.m., she indicated she would prefer her fingernails to be trimmed and cleaned. After a dressing change observation on 8-19-22 at 3:15 p.m., with LPN 3 and CNA 4, both staff members were queried as to Resident H's fingernail status. Both staff members replied they had not noticed anything unusual until it was brought to their attention at the time of query. On 8-19-22 at 4:30 p.m., the Administrator provided a copy of an undated policy entitled, Activities of Daily Living (Routine Care). This policy was indicated to be the current policy utilized by the facility. This policy indicated, Residents are given routine daily care and HS [bedtime] care by a C.N.A. or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed. ADL care is coordinated between the resident and the care givers with emphasis on resident preference as much as possible .ADL care of the resident includes: assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care .assisting with movement and ambulation and ROM [range of motion] as indicated and care planned .do all required ADL documentation as required per policy and regulations. This Federal tag relates to Complaint IN00387621. 3.1-38(a)(2)(A) 3.1-38(a)(2)(B) 3.1-38(a)(3)(B) 3.1-38(a)(3)(E) 3.1-38(B)(2) 3.1-38(B)(3) 2,) Review of the record of Resident B on 8/18/22 at 11:40 a.m., indicated the resident's diagnoses included, but were not limited to, down syndrome, autoimmune hepatitis, atelelctasis, muscle wasting and atrophy, muscle weakness, difficulty walking and right hip joint replacement. The physical therapy evaluation and plan of treatment for Resident B, dated 2/1/22, indicated the resident was totally dependent of one staff to transfer. The admission MDS assessment, dated 2/7/22, indicated the resident was severely impaired for daily decision making. The resident was not transferred during the assessment period. The ADL documentation for Resident B, dated February 2022, indicated the resident was transferred 11 times in 28 days. During an interview with Resident B's family member on 8/23/22 at 1:59 p.m.,, indicated the resident was suppose to be gotten out of bed daily. The Family member indicated she had talked to the facility about the concern of the resident not being transferred out of bed on a daily basis. The family member indicated they visited the facility almost daily and the resident had only been gotten up a few times during her stay at the facility. During an interview with the Director Of Nursing on 8/23/22 at 10:28 a.m., indicated the management team would be responsible to ensure dependent residents were assisted out of bed per their preference. The CNA's would be responsible to transfer dependent residents out of bed. Based on observation, interview and record review the facility failed to assist residents with Activities of Daily Living (ADLs) assistance with grooming, showers and nail care for 3 of 4 residents reviewed for ADL assistance. (Residents D, H, and B) Findings include: 1. On 8/17/22 at 10:51 a.m., Resident D was observed with her hair disheveled and uncombed. She indicated she has been here since Thursday (6 days) and has had no shower since admission. Resident D's record was reviewed on 8/19/22 at 10:24 a.m. and indicated diagnosis that included, but were not limited to, wedge compression fracture of the first lumbar vertebra, high blood pressure, high blood fats, and acute pain due to trauma. A five day Medicare Minimum Data Set assessment, still in progress, indicated completed sections for the following: resident was cognitively intact, required extensive assistance of one for bed mobility, limited assistance of one for transfers, eating, bathing, and walking, and extensive assistance of one for dressing, toileting, and personal hygiene including combing hair. An admission Activity Resident Interview, dated 8/11/22 indicated it is somewhat important for her to choose between a tub bath, shower, bed bath or sponge bath. An Activity admission Assessment, dated 8/12/22, indicated she was cognitively intact, hearing was normal, had no problem with verbal communication, speech was clear, and she preferred showers. A care plan dated 8/11/22 indicated: Resident requires assistance with ADL'S. Goal: Resident will have all ADLS met by staff TNR (through next review). Interventions: Assist as needed so resident is clean and dry. Bathe per resident preference 2x [weekly]. Follow patient preferences as detailed on CNA pocket worksheet. Keep call light in reach. Notify and update MD and family as needed. staff assist as needed with bed mobility. staff assist as needed with eating. staff assist as needed with transfers. staff assist with toileting as needed. therapy screen as needed and quarterly. On 8/19/22 at 10:50 a.m., Resident D was lying in bed with her TV on. Her hair was uncombed and she said no one has helped her with her hair today but they will brush her hair if she asks them. She said she lets them brush it but she likes to pull it up herself because she can't get it down after they put it up for her. On 8/22/22 at 4:25 p.m., two family members were visiting Resident D and both indicated she has not had a shower since she has been here. Resident D said she combed her hair herself with her fingers today. Said she has not had her hair shampooed since admission either. Resident said she prefers showers to bed baths. On 8/23/22 at 1:55 p.m., Resident D indicated she has not yet had a shower, nor a shampoo, and her hair was observed to be very fly away and uncombed. Review of shower sheets and shower documentation under the task section for CNA notes indicated no documented shower since admission. On 8/23/22 at 12:03 p.m., p.m., CNA 5 indicated there is a sheet at the nurse's station that has the shower days on it. She said if a resident refuses a shower, it is written on the shower sheet and the nurse would document it too. LPN 6 indicated if a resident refused, the nurse would talk to the resident and see if a different time or day would be better, and it would also be documented in the progress notes. The shower schedule indicated Resident D's showers would be on Wednesday and Saturday, which indicated she should have had three showers since admission. Review of progress notes dated 8/11/22 through 8/23/22 did not indicate any notes related to Resident showers or refusal of showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement fall interventions for residents who were at high risk of falls for 2 of 6 reviewed for accidents (Resident 12 and Resident 22). Findings include: 1.) During an observation on 8/18/22 at 1:40 p.m., Resident 22 was sitting in her wheelchair in her room brushing her hair, the resident had a rolling bedside table sitting beside her. During an observation on 8/19/22 at 10:55 a.m., Resident 22 was sitting in a wheelchair in her room with a rolling bedside table beside her. During an observation on 8/23/22 at 11:03 a.m., Resident 22 was laying on couch with a rolling bedside table next to her with a drink on it. During an interview with LPN 7 ON 8/23/22 at 11:06 a.m., indicated she was the nurse caring for Resident 22. LPN 7 indicated she was unsure who was responsible to ensure the fall intervention of not having a bedside table in her room was implemented. LPN 7 indicated it would be all the staff's responsibility to ensure fall interventions were in place. During an interview with the Director Of Nursing (DON) on 8/23/22 at 11:23 a.m., indicated it was all staff's responsibility to ensure fall interventions were in place. The CNA's were verbally told what fall interventions were to be implemented for each resident and also the interventions were on the residents [NAME]. The DON indicated LPN 7 had reported to her that Resident 22 had a rolling bedside table in her room and the CNA removed it from the room. The DON indicated the resident was not suppose to have a rolling bedside table in her room because had attempted to use it as a walker and fell. Review of the record of Resident 22 on 8/23/22 at 1:15 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, schizoaffective disorder and repeated falls. The Quarterly Minimum Data Set (MDS) assessment for 22, dated 6/27/22, indicated the resident was severely impaired for daily decision. The resident required extensive assistance of two people for transfers, the resident required limited assistance of one person to walk in her room. The resident's mobility devices were walker and wheelchair. The resident has had two or more falls since previous MDS and one with an injury. The Interdisciplinary team (IDT) progress note for Resident 22, dated 7/6/22 at 5:30 p.m., indicated the resident had been ambulating in her room using a rolling bedside table to walk with instead of a walker and fell. The new intervention would be to have the bedside table removed from the residents room and provide resident with meals outside of her room so staff could monitor for safety. The fall risk assessment for Resident 22, dated 7/18/22, indicated the resident was at high risk for falls. The plan of care for Resident 22, revision date 7/21/22, indicated the resident was at risk for falls due to history or recent fall, impaired balance, anemia, dementia, incontinence, arthritis, wandering, depression with antidepressant use and visual depth perception deficit. The interventions included, but were not limited to, remove rolling bedside table from her room (7/6/22). The incident report for Resident 22 provided by the DON on 8/23/22 at 2:50 p.m., indicated the resident had fell 11 times in the past 3 months. 2.) During an observation on 8/19/22 at 2:12 p.m., Resident 12 was sitting in her room in a walker drinking coffee. The resident did not have a bedside commode in her room. Review of the record of Resident 12 on 8/24/22 at 11:07 a.m., indicated the resident's diagnoses included, but were not limited to, mild cognitive impairment, history of falling, unsteadiness on feet, osteoarthritis and vertigo. The plan of care for Resident 12, dated 1/4/22, indicated the resident was at risk for falls due to a history of falls. The interventions included, but were not limited to, bedside commode to be provided to resident (5/11/22). The IDT progress note for Resident 12, dated 5/11/22 at 12:36 a.m., met to review fall. At time of fall resident was attempting to transfer into bathroom. At time of fall resident was in her wheelchair which has extended break handles, proper footwear, and light to the bathroom was on. Immediate Intervention for a bedside commode to be provided for resident to allow more room for resident to transfer onto toilet. care plan reviewed and updated. The fall risk assessment for Resident 12, dated 5/11/22, indicated the resident was at high risk for falls. During an interview with Resident 12 on 8/24/22 at 11:00 a.m., resident indicated she had never had a bedside commode none observed in room she indicated she would like to have one because when she needs to go to the bathroom she needs to go right away. During an interview with QMA 8 on 8/24/22 at 11:05 a.m., indicated she did care for Resident 12 and was unsure if she had ever seen a bedside commode in her room. During an interview with LPN 7 on 8/24/22 at 11:10 a.m., indicated it had been awhile since she seen a bedside commode in Resident 12's room but was unable to say how long it had been. The LPN indicated she thought the facility may have taken it out for some reason unknown to her. The fall policy provided by the DON on 8/24/22 at 9:15 a.m., indicated based on the results of the fall investigation the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. 3.1-(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The clinical record of Resident 29 was reviewed on 8-18-22 at 10:30 a.m. His diagnoses included, but were not limited to a history of urinary tract infections. His admission Minimal Data Set assessment, dated 7-3-22, indicated he was cognitively intact, required limited assistance of 2 or more persons for toileting and was continent of bowel and bladder. It did not indicate any use of a urinary catheter device. In observations on 8-15-22 at 1:54 p.m. and 8-18-22 at 11:20 a.m., Resident 29's urinary catheter bag was lying on the floor. In an interview with Resident 29 on 8-18-22 at 11:20 a.m., he indicated the nursing staff usually hangs his catheter bag off of the bedframe. He denied any pain or discomfort with the indwelling catheter. Resident indicated he did not have a catheter prior to fracture of his leg and has been at facility since June, 2022. Resident 29 indicated he was informed the reason for his urinary catheter was that since he was unable to walk, it would be easier for him to deal with urination. In an interview with CNA 2 on 8-18-22 at 1:16 p.m., she indicated Resident 29 was able to urinate without problems when he first admitted to the facility. She indicated, He started having problems with being able to urinate; he would try and strain and he had a terrible time. At first, the nurses would in and out cath him and sometimes would get 1000 cc's. I can't remember exactly when he got a foley catheter put in, but he seems a lot more comfortable. In review of Resident 29's clinical record, there was a lack of physician orders located in the clinical record for placement of an anchored catheter or catheter care, as of 8-18-22 at 11:20 a.m. Later in the day of 8-18-22, a review of Resident 29's clinical record reflected the presence of physician orders for the urinary catheter with a reason for the placement and associated care plans for the same. A review of the nursing progress notes, after placement of the indwelling catheter on 7-18-22 or 7-19-22, there was intermittent documentation of the resident's urinary status not reflective of the indwelling catheter, as follows: -7-21-22 at 12:01 a.m.: continent. -7-21-22 at 6:21 p.m.: incontinent of bowel and bladder. -7-23-22 at 11:40 a.m.: incontinent of bowel and bladder. -7-26-22 at 11:25 p.m.: continent. -8-14-22 at 12:06 a.m.: continent. -8-16-22 at 1:03 a.m.: continent. In an interview with the Director of Nursing (DON) on 8-18-22 at 2:10 p.m., she indicated a nursing progress note, dated 7-18-22, demonstrated the nurse had called and obtained a physician order for the catheter but it did not get transcribed (properly written and entered into the electronic medical record). The DON provided a copy of the order which reflected on 7-18-22, but noted to be dated 8-19-22, as the date of confirmation, the MDS Coordinator obtained an order from the resident's attending physician, which indicated the facility was to place an indwelling catheter for urinary retention with the catheter, which included the size of catheter and the balloon size and to change it every 30 days and as needed. On 8-23-22 at 8:55 a.m., in an interview with the DON, she indicated, I haven't really looked at [name of Resident 29]'s documentation about his catheter. I know he had a catheter before he admitted here. I don't think he had one when he first came to us. He also had several in and out caths before he had one anchored. Maybe the documentation of him being continent or incontinent had to do with his bowels. Plus, he would take himself to the bathroom at times without asking for help and not put the cath bag back where it was off the floor. Last week, once we knew you were looking at concerns with catheters [during the annual survey process], we did an audit of all the residents with catheters. So, that is when we starting looking at the cath orders .I think part of the problem with some of our documentation has to do with having so many agency staff during Covid. I could never figure out how to motivate them to get the documentation that was required done. At one point, we had up to 95% of the staff that was agency staff. Starting this spring, we have been able to begin to get new staff and we are now completely without any agency staff and we can begin to get more training completed. 3. The clinical record of Resident H was reviewed on 8-19-22 at 11:22 a.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, muscle wasting and atrophy, history of repeated falls, atherosclerosis of right leg w/ulceration of part of foot, mild cognitive impairment, diabetes, dementia, personal history of Covid-19 (12-1-21 and 8-15-22), history of diabetic foot ulcer, polyneuropathy and pressure ulcer to coccyx. Her most recent Minimum Data Set assessment, dated 6-24-22, indicated she was cognitively impaired, required extensive assistance of one person for personal hygiene activities, such as nail care, and was dependent for assistance with bathing of one person. Observations were conducted on 8-17-22 at 1:48 p.m. and 8-18-22 at 2:12 p.m. in which Resident H's catheter bag was observed to be in contact with the floor. In an observation and interview with Resident H on 8-18-22 at 2:12 p.m., she indicated she has had a urinary catheter for an unknown amount of time and for an unknown reason. The catheter bag bottom was observed in contact with the floor and not attached to bed frame. The urine in the catheter tubing was observed to be a clear yellow color without any sediment. Resident H indicated she has a history of urinary tract infections (UTI's) and currently has some low abdominal discomfort and some pelvic area pain and burning; she is uncertain if she is currently being treated for a UTI. A physician's order, dated 5-22-22, indicated to place an indwelling urinary catheter for wound healing, with directions to replace the catheter every 30 days on the 22nd of each month. The catheter order did not specify the size of the tube or balloon of the catheter. Another catheter order, dated 6-17-22, did not specify the size of the tube or balloon of the catheter. A catheter order, dated 8-18-22 at 7:00 p.m., indicated, Catheter: Change fig bag/drainage bag with privacy bag twice a month every night shift every 14 days for catheter care. A catheter order, initiated on 8-18-22 at 7:00 p.m., indicated to place an indwelling catheter for wound healing, specifying the catheter size and to be replaced every 30 days. This order was discontinued on 8-19-22 at 7:00 p.m., and replaced with a different-sized catheter for wound healing and to be replaced every 30 days. None of the catheter-related orders alluded to conducting routine catheter-cleaning care. A review of the clinical record indicated Resident H had been recently treated for UTI's, based on urinalysis testing on 7-9-21 and 8-1-22, as follows: -Macrobid 100 milligrams (mg) twice daily for 7 days from 7-14-22 until 7-21-22. -Cipro 500 mg twice daily for 10 days from 8-2-22 until 8-11-22. On 8-23-22 at 8:55 a.m., in an interview with the DON, she indicated, in the previous week, it had come to the attention of the facility during the facility's annual survey, the survey team was looking at catheter-related issues. We did an audit of all the residents with catheters. So, that is when we starting looking at the cath orders. 4.) During an observation on 8/16/22 at 2:32 p.m., Resident 159 was laying in bed with a catheter in place in a privacy bag hanging on the frame of the bed. Review of the record of Resident 159 on 8/24/22 at 10:00 a.m., indicated the resident's diagnoses included, but were not limited, dysfunction of the bladder and cerebral palsy. The progress note for Resident 159, dated 7/21/2022 at 5:00 p.m., indicated the resident was admitted to the facility with a Foley catheter in place. The plan of care for Resident 159, dated 8/10/22, indicated the resident had a Foley catheter. The interventions were, change indwelling Foley catheter as ordered, complete catheter care every shift, update the physician and family of any changes as needed and urology follow up as needed/ordered. This indicated the resident did not have a plan of care for Foley catheter for 21 days after his admission to the facility. The physician order for Resident 159, dated 8/19/22, indicated the resident was ordered a urinary catheter size 22 french with 30 cc balloon to bed changed every thirty days or every 24 hours as needed for occlusion. This indicated the resident had not had a physician order in place for the Foley catheter for 30 days after his admission to the facility. The indwelling urinary catheter care policy provided by the Administrator on 8/19/22 at 4:30 p.m., indicated the purpose was to cleanse and maintain hygiene to perineal area and indwelling catheter. To remove mucous from around indwelling catheter to prevent excoriation, inflammation and discomfort. The procedure included, but were not limited to, enter the physician order to include the type of catheter, size of catheter and diagnosis for the catheter. The facility would implement a plan of care for the indwelling catheter to perform catheter care, check catheter tubing for proper drainage and positioning, keep catheter below the bladder and observe for good infection control techniques. 3.1-47(a)(3) Based on observation, interview, and record review, the facility failed to ensure resident's catheter drainage bags did not touch the floor, failed to have complete documentation of urine output and complete physician's orders for the catheter and catheter care, and failed to have physician's orders and a plan of care for a catheter. This affected 4 of 5 residents reviewed for urinary catheters. (Residents 7, H, 29 and 159) Findings include: 1. Resident 7's record was reviewed on 8/18/22 at 2:40 p.m. and indicated diagnoses that included, but were not limited to, fracture of upper and lower end of right fibula (lower leg), acute kidney failure, and high blood pressure. A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 7 was mildly cognitively impaired, and had an indwelling Foley catheter. A care plan, dated 4/21/22, indicated Resident has an indwelling catheter related to BPH (benign prostatic hyperplasia) with obstruction. Goal: Resident will be free of S/Sx of infection related to indwelling catheter, and catheter will remain patent daily through next review. Interventions .Maintain drainage bag and tubing to prevent discomfort or infection On 8/22/22 at 4:10 p.m., Resident 7's catheter drainage bag was observed lying on the floor, the dignity cover was on it but the top and bottom part of the catheter drainage bag was in contact with the floor. On 8/22/22 at 4:15 p.m., CNA 5 indicated she put the bag on the bed frame and it must have slid off when the resident moved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents reviewed for oxygen therapy and associated respiratory issues had physician orders for the use of a CPAP (continuous positive airway pressure) machine were in place and care plans for oxygen and CPAP usage were in place within one month of admission and failed to conduct and document daily, or more often, oxygen saturation levels. (Resident 41) Findings include: The clinical record of Resident 41 was reviewed on 8-19-22 at 2:35 p.m. His diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease or lung disease), obstructive sleep apnea and heart failure. His admission Minimum Data Set (MDS) assessment, dated 7-17-22, indicated he was cognitively intact and indicated he received supplemental oxygen therapy, but did not indicate he utilized CPAP therapy. In an observation and interview of Resident 41 on 8-22-22 at 11:25 a.m., he was observed wearing supplemental oxygen via a nasal cannula with the rate at two liters per minute, with his respirations nonlabored. A CPAP machine was observed located on his bedside table. In an interview at this time, Resident 41 indicated he used the oxygen during the day and at night time, he uses the oxygen plus his CPAP. He indicated he has not had oxygen saturation levels checked daily by facility staff, as it had been occurring once daily or once every other day or sometimes less often. I figured they would check on [my] oxygen level at least once or twice a day. I would really like them to check it at least once a day. He indicated he brought the CPAP machine from home upon admission and had obtained it from his insurance and medical provider. In review of Resident 41 documents that reflected the facility's documentation of his oxygen saturation levels, it indicated on his admission on [DATE], it was documented as 98% (percent). The next documentation of his oxygen saturation was not dated until 7-28-22, 15 days later. A review of Resident 41's physician orders for July and August, 2022, provided by the Administrator on 8-22-22 at 1:40 p.m., failed to reflect any orders for the use of a CPAP machine or settings for it. An order for the continuous usage of oxygen at 2 liters per minute via nasal cannula was ordered upon admission, on 7-13-22. No orders were in place for checking of the oxygen saturation until 7-27-22. The initial admission nursing assessment, dated 7-13-22, indicated Resident 41 utilized oxygen therapy, with an oxygen saturation rate of 98% and had brought in a CPAP machine from home. The documentation failed to identify the settings for the CPAP machine. In an interview with the MDS Coordinator and the Social Services Designee (SSD) on 8-22-22 at 2:45 p.m., the SSD provided copy of Resident 41's initial care plan meeting with his family, dated 7-14-22. The initial care plan meeting indicated he utilized oxygen, but did not address the use of a CPAP machine. The MDS Coordinator indicated the current care plans did not address the concerns of his diagnoses of COPD, cardiac-related health issues and usage of supplemental oxygen and a CPAP machine. The MDS Coordinator indicated the current care plans did not reflect concerns with COPD, oxygen usage, CPAP usage or heart health issues. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Oxygen Administration. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician .Residents with oxygen orders, routine and PRN, will have oxygen saturation levels measured by oximetry per physician order indicating clinical oxygen saturation to be maintained. Oxygen saturation will be checked and documented every shift to meet order specifications .Pulse Oximetry: Residents who have oxygen orders, whether scheduled or PRN will have oxygen saturation levels measured no less than daily. If MD orders states 'to maintain Sat' then oxygen saturation will be checked and documented every shift. MD will be notified whenever titration is required to maintain a saturation, which indicate a change in condition. Lung sounds and assessment will be reported to the MD at that time. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Continuous Positive Airway Pressure (CPAP). This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, Purpose: To improve ventilation on patients with obstructive sleep apnea (OSA), airway obstruction and upper airway resistance .Guideline: CPAP therapy must have a written physician's order. The order must include the level of CPAP, FIO2, if needed, and humidifier, if needed. The patient should be assessed before and after therapy has been initiated for any hazards or adverse effects such as pneumothorax and gastric distension .Procedure: Verify physician's order .order must include the level of CPAP, e.g. 5 cm H2O .Set CPAP level according to the physician ordered level . On 8-22-22 at 3:12 p.m., the Administrator provided a copy of a policy and procedure, entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 9-18-18. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of the facility to ensure every resident has a Baseline Care Plan completed and implemented within 48 hours of admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed. The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan .Procedure: Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concerns. At a minimum, it will address initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations. Observations, interview(s) with the resident and/or representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT team . The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAA's . 3.1-47(a)(6)