Based on record review and interview, the facility failed to accurately complete a preadmission screening to determine the need for a PASRR II for one (#43) of one sampled resident admitted to the facility. The Resident Census and Conditions of Residents documented 52 residents resided in the facility. Findings: A .Oklahoma Health Care Authority, Nursing Facility Level of Care Assessment, dated 06/17/22, read in parts, .admission Date 06/15/2022 .Level II required [blank] .Diagnosis of a serious mental illness (for example schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder, somatoform disorder, personality disorder, or other psychotic disorder, or another mental disorder, or another mental disorder that may lead to a chronic disability? [No] . On 01/10/23 12:42 PM an interview with the DON was conducted. The DON was asked if the PASRR included her diagnosis for Major Depressive Disorder. The DON stated, no. DON was asked if the question in the PASRR was answered correctly. DON stated, no, but she knew the resident had anxiety, dementia, and depression. The facility PASRR POLICY, dated 10/31/22, read in parts, .Prior to admission all potential residents must be screened for the need for a level two PASSR. If a need is established you must contact OHCA .

Based on record review and interview, the facility failed to ensure and document scheduled cleaning for the BIPAP machine for one #43 of one sampled resident with a BIPAP. The Resident Census and Conditions of Residents documented 52 residents resided in the facility. Findings: The Significant Change Assessment, dated 12/12/22, did not document BIPAP on the assessment. The Physician's Order, dated 12/13/21, documented, .BIPAP @HS at bedtime related to sleep apnea . On 01/10/23 at 03:20 p.m., the ADON was asked for documentation for the cleaning/use of the BIPAP machine. She reported she had discussions with the resident's husband that he would clean the BIPAP, and stated she could change the physician's order and have the staff clean the machine. On 01/10/23 at 03:27 p.m., resident #43's BIPAP machine was observed on the bedside table in her room. Resident #43 was asked who cleaned her BIPAP machine. She reported she did not know who cleaned her BIPAP machine. She stated her husband used to clean it and they had asked him to take the cleaning machine home a few weeks ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure MDS assessments accurately reflected the residents status for three (#17, 43, and #45) of eighteen sampled residents reviewed for assessments. The Resident Census and Conditions of Residents form documented 52 residents resided in the facility. Findings: 1. Resident #17 had diagnoses which included dementia, fractures, and diabetes. An incident report, dated 12/04/22, documented the resident had a fall with right femur fracture. The Significant Change Assessment, dated 12/19/22, documented under the section for Fall History Did the resident have a fall any time in the last month It was answered, No. On 01/08/23 at 9:30 a.m., the MDS coordinator reported, I should have marked the resident had a fall as yes not no. 2. Resident #43 had diagnosis which included sleep apnea. The Significant Change Assessment, dated 12/12/22, documented the resident's cognition was intact. The Progress Note, dated on 01/03/23, documented the resident chose not to allow staff to put on BIPAP, with no other behaviors reported. The Progress Note, dated on 01/10/23, documented resident did not allow staff to put on BIPAP at the end of the previous shift or the beginning of this shift. On 01/10/23 at 09:28 a.m., resident #43 reported she used her BIPAP if staff remembered to put it on her at night. On 01/10/23 at 03:04 p.m., the MDS coordinator was asked if the BIPAP was recorded on the MDS. She stated no it was not recorded, but should have been recorded under special treatments and procedures. 3. Resident #45 had diagnosis which included sleep apnea. The Physician's Orders, dated 10/17/22, documented CPAP to be worn at night every night shift related to sleep apnea. The resident's annual Minimum Data Set (MDS), dated 10/21/22, did not document CPAP under special treatments and procedures. On 01/09/23 at 02:11 p.m., resident #45 was lying in bed with oxygen in place at 2L NC and a CPAP machine was observed on the bedside table. On 01/17/23 at 03:51 p.m., the MDS Coordinator was asked if the admission MDS dated [DATE] included the physician's orders for CPAP. She stated no it did not, but should have been on there.