Health inspection·December 22, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the supplemental oxygen was administered as ordered by the physician and by the competent staff for four of five sampled residents (Residents 1, 2, 3, and 5). Residents Affected - Some * Supplemental oxygen was not administered as ordered for Residents 1, 2, and 3. * Resident 5's supplemental oxygen was administered and removed by a CNA. These failures had the potential to put the residentsat risk of respiratory complications. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2020 showed to verify and review the physician's order before administering the oxygen and after the oxygen set up or adjustment. 1. Closed medical record review for Resident 1 was initiated on 12/20/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/4/23. On 12/20/23 at 0913 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated one day when they arrived around 0900 hours to visit Resident 1, they found him up in his wheelchair in the activity room without any supplemental oxygen. Family Member 1 stated there was no oxygen tank or tubing with Resident 1. Family Member 1 stated the staff told her Resident 1 was brought to the activity room around 0800 hours. Review of Resident 1's physician's orders showed an order dated 11/28/23, for continuous supplemental oxygen to be administered at 2-5 lpm. On 12/20/23 at 1449 hours, a concurrent interview and closed record review was conducted with the MDS Coordinator. The MDS Coordinator stated in the morning of Resident 1's care conference meeting, Family Member 1 informed the MDS Coordinator that Resident 1 was in the activity room without supplemental oxygen. The MDS Coordinator stated she notified the ADON and put in a work order request for the maintenance staff to install an oxygen cylinder holder on the resident's wheelchair. The MDS Coordinator reviewed Resident 1's medical record and verified Resident 1's Resident Care Conference Review was held on 12/1/23. Review of the Facility's Nursing Assignment for 12/1/23,showed CNA 4 was assigned to Resident 1 for Page 1 of 10 055575 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0695 the 0700-1500 hours shift. Level of Harm - Minimal harm or potential for actual harm On 12/21/23 at 0921 hours, an interview was conducted with the ADON. The ADON stated the MDS Coordinator informed her that Resident 1 was found in the activity room without their ordered supplemental oxygen. The ADON stated CNAs were not allowed to remove or apply the supplemental oxygen and they should notify the licensed nurses when it needed to be removed or applied. Residents Affected - Some On 12/21/23 at 1528 hours, a telephone interview was conducted with CNA 4. CNA 4 stated they recalled being assigned to Resident 1 and taking the resident to the activity room. CNA 4 stated the resident was in bed with oxygen being administered by an oxygen concentrator (a medical device that takes air from its surroundings, extracts the oxygen and filters it into purified oxygen to be administered as supplemental oxygen). CNA 4 stated they removed the oxygen to bathe the resident and get him dressed. CNA 4 stated they did not check with the nurse see if Resident 1 needed continuous supplemental oxygen. 2. Medical record review of Resident 2 was initiated on 12/20/23. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 12/20/23, showed a physician's order dated 10/6/23, for oxygen to be administered at 2-5 lpm continuously. On 12/20/23 at 0812 hours, Resident 2 was observed lying in bed. No supplemental oxygen was observed in use. On 12/20/23 at 1022 hours, Resident 2 was observed lying in bed. No supplemental oxygen was observed being administered to the resident. On 12/20/23 at 1045 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 2 did not need supplemental oxygen on all day, just sometimes when he wentoutside. On 12/20/23 at 1051 hours, a concurrent observation and interview was conducted with the ADON at Resident 2's bedside. The ADON stated Resident 2 had a PRN oxygen order and verified the resident was not currently receiving the supplemental oxygen. When asked to verify the physician's order, the ADON looked up Resident 2's physician's orders and stated it was for continuous supplemental oxygen. On 12/20/23 at 1055 hours, an interview was conducted with LVN 3. LVN 3 stated they were assigned to Resident 2 and the resident had been on room air since they started their shift. Review of Resident 2's Medication Administration Record for December 2023 showed Resident 2 was administered 2-5 lpm of supplemental oxygen each shift from 12/1/23-12/19/23. The records failed to show the specific rate the resident received. Review of Resident 2's SBAR Communication Form and progress notes dated 12/17/23, showed Resident 2 was on room air. Review of Resident 2's N Adv – Skilled Evaluation V6.3 note dated 12/13/23 at 1317 hours, showed Resident 2 was on room air. Review of Resident 2's N Adv – Skilled Evaluation V6.3 note dated 12/14/23 at 1316 hours, 055575 Page 2 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0695 showed Resident 2 was on room air and not receiving supplemental oxygen. Level of Harm - Minimal harm or potential for actual harm On 12/21/23 at 1408 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 2's above physician's order for continuous supplemental oxygen to be administered at 2-5 lpm. LVN 2 verified the above medical record showed Resident 2 did not receive supplemental oxygen as ordered by the physician. Residents Affected - Some 3. Medical record review of Resident 3 was initiated on 12/20/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's orders showed a physician's order dated 12/2/23, for supplemental oxygen 2-5 lpm to be administered every shift. On 12/20/23 at 0805 hours, Resident 3 was observed lying in their bed with their eyes closed without supplemental oxygen in use. An oxygen concentrator was observed in the corner of the room by Resident 3's foot of the bed. On 12/20/23 at 1028 hours, Resident 3 was observed lying in their bed with their eyes closed. No supplemental oxygen was in use. On 12/20/23 at 1159 hours, a concurrent interview and observation was conducted with CNA 3. CNA 3 stated they were assigned to Resident 3 that day. CNA 3 stated Resident 3 sometimes needed supplemental oxygen. CNA 3 stated Resident 3 was on oxygen when they saw him this morning, but the resident removed it when he went outside in the morning and it hadbeen off since. CNA 3 observed Resident 3 and verified the resident was not on supplemental oxygen. On 12/20/23 at 1101 hours, an interview was conducted with Resident 3 in their room. Resident 3 stated they only used supplemental oxygen as needed and did not need it all the time. On 12/20/23 at 1102 hours, a concurrent interview, observation, and medical record review were conducted with LVN 1. LVN 1 stated Resident 3 was not currently on supplemental oxygen and did not always need it. LVN 1 reviewed Resident 3's physician's order and verified the order was for continuous supplemental oxygen to be administered. Review of Resident 3's Medication Administration Record for December 2023 showed Resident 3 was administered 2-5 lpm of supplemental oxygen each shift from 12/1/23 -2/20/23, during the 0700-1500 hours shift. The medical record review failed to show the specific oxygen flow rate the resident received. Review of Resident 3's COMS – Clinical admission Evaluation note dated 12/2/23 at 2201 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/8/23 at 0127 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/8/23 at 2338 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/10/23 at 0129 hours, 055575 Page 3 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0695 showed Resident 3 was on room air. Level of Harm - Minimal harm or potential for actual harm Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/11/23 at 0027 hours, showed Resident 3 was on room air. Residents Affected - Some Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/12/23 at 0422 hours, showed Resident 3 was on 2 lpm of supplemental oxygen. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/13/23 at 0059 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/14/23 at 0132 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/15/23 at 0031 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/16/23 at 0104 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/17/23 at 0311 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/18/23 at 0122 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/19/23 at 0140 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/20/23 at 0139 hours, showed Resident 3 was on room air. On 12/21/23 at 1332 hours, an interview and concurrent medical record review were conducted with LVN 2. LVN 2 verified Resident 3's above physician's order for continuous supplemental oxygen to be administered at 2-5 lpm. LVN 2 verified the above medical record showed Resident 3 did not receive supplemental oxygen as ordered by the physician. 4. Medical record review for Resident 5 was initiated on 12/22/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's physician's orders showed a physician's order dated 12/20/23, for the supplemental oxygen to be administered at 2-5 lpm continuously. On 12/22/23 at 0744 hours, CNA 2 was observed at Resident 5's bedside. Resident 5 was up in their wheelchair without supplemental oxygen. CNA 2 was observed rolling Resident 5 away from their bed, applying a nasal cannula tothe resident's nares, and turning an oxygen regulator dial. CNA 2 stated they removed the nasal cannula connected to the oxygen concentrator. CNA 2 stated they turned the oxygen regulator to 2 lpm so she could bring the resident to the feeding program room for breakfast. When asked how much oxygen Resident 5 was on before she turned off the oxygen concentrator, CNA 2 055575 Page 4 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0695 stated she was not sure. Level of Harm - Minimal harm or potential for actual harm On 12/22/23 at 0753 hours, an interview was conducted with LVN 3. LVN 3 stated they were assigned to Resident 5 that day. LVN 3 stated Resident 5 received supplemental oxygen. When asked how much oxygen Resident 5 was on that morning, the LVN stated she was not sure and had not made her rounds yet. LVN 3 stated it was the LVNs responsibility to set up the residents' oxygen. Residents Affected - Some On 12/22/23 at 0921 hours, an interview was conducted with the ADON. The ADON stated supplemental oxygen was considered a medication and may not be removed or applied by a CNA. 055575 Page 5 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and medical record review, the facility failed to ensure the medical records were accurate and complete for four of five sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to not effectively evaluate the care and services provided and residents' health conditions. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2020 showed to verify and review the physician's order before administering oxygen and after oxygen set up or adjustment, the following should be recorded in the resident's medical record: the date and time, rate of oxygen flow, route and rational, frequency and duration of the treatment, reason for PRN administration, and how the resident tolerated the procedure. 1. Medical record review of Resident 2 was initiated on 12/20/23. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 12/20/23, showed a physician's order dated 10/6/23, for oxygen to be administered at 2-5 lpm continuously. Review of Resident 2's Medication Administration Record for December 2023 showed Resident 2 was administered 2-5 lpm of supplemental oxygen each shift from 12/1/23 - 12/19/23. The medical record review failed to show the specific rate the resident received. Review of Resident 2's SBAR Communication Form and progress notes dated 12/2/23, showed Resident 2 was on 2 lpm of supplemental oxygen. Review of Resident 2's SBAR Communication Form and progress notes dated 12/17/23, showed Resident 2 was on room air. Review of Resident 2's N Adv – Skilled Evaluation V6.3 note dated 12/7/23 at 1156 hours, showed Resident 2 was on 2 lpm of supplemental oxygen. Review of Resident 2's N Adv – Skilled Evaluation V6.3 note dated 12/13/23 at 1317 hours, showed Resident 2 was on room air. Review of Resident 2's N Adv – Skilled Evaluation V6.3 note dated 12/14/23 at 1316 hours, showed Resident 2 was on room air and not receiving supplemental oxygen. On 12/20/23 at 1055 hours, an interview was conducted with LVN 3. LVN 3 stated they were assigned to Resident 2, and the resident had been on room air since they started their shift. On 12/21/23 at 1408 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 2's above physician's order for continuous supplemental oxygen to be administered at 2-5 lpm. LVN 2 reviewed Resident 2's medical record and verified the above documentation for supplemental oxygen usage. LVN 2 verified Resident 2's oxygen use was not documented routinely to show how much oxygen the resident was on, as well as when and why the resident's oxygen use was 055575 Page 6 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0842 increased/decreased and the resident's response to the changes. Level of Harm - Potential for minimal harm On 12/21/23 at 1551 hours, an interview was conducted with the DON. The DON stated supplemental oxygen use should be documented in the MAR and daily Skilled Evaluation charting. The DON stated there wasa section specifically for supplemental oxygen use and the nurses should be completing that section for all residents with supplemental oxygen. Residents Affected - Some 2. Medical record review of Resident 3 was initiated on 12/20/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's orders showed a physician's order dated 12/2/23, for the supplemental oxygen 2-5 lpm to be administered every shift. Review of Resident 3's Medication Administration Record for December 2023 showed Resident 3 was administered 2-5 lpm of supplemental oxygen each shift from 12/1/23 - 12/20/23, during the 0700-1500 hours shifts. The medical record review failed to show the specific oxygen flow rate the resident received. Review of Resident 3's COMS – Clinical admission Evaluation note dated 12/2/23 at 2201 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/4/23 at 0222 hours, showed Resident 3 was on 2 lpm of supplemental oxygen. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/5/23 at 0251 hours, showed Resident 3 was on 2 lpm of supplemental oxygen. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/6/23 at 0258 hours, showed Resident 3 was on 2 lpm of supplemental oxygen. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/7/23 at 0014 hours, showed Resident 3 was on 2 lpm of supplemental oxygen. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/8/23 at 0127 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/8/23 at 2338 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/10/23 at 0129 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/11/23 at 0027 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/12/23 at 0422 hours, showed Resident 3 was on 2 lpm of supplemental oxygen. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/13/23 at 0059 hours, 055575 Page 7 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0842 showed Resident 3 was on room air. Level of Harm - Potential for minimal harm Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/14/23 at 0132 hours, showed Resident 3 was on room air. Residents Affected - Some Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/15/23 at 0031 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/16/23 at 0104 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/17/23 at 0311 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/18/23 at 0122 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/19/23 at 0140 hours, showed Resident 3 was on room air. Review of Resident 3's N Adv – Skilled Evaluation V6.3 note dated 12/20/23 at 0139 hours, showed Resident 3 was on room air. On 12/20/23 at 1101 hours, a concurrent interview and observation was conducted with Resident 3. Resident 3 stated they only use supplemental oxygen when needed, usually at night. Resident 3 stated he was on supplemental oxygen last night and removed it this morning. On 12/21/23 at 1332 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 3's above physician's order for continuous supplemental oxygen to be administered at 2-5 lpm. LVN 2 reviewed Resident 3's medical record and verified the above documentation for supplemental oxygen usage. LVN 2 verified Resident 2's oxygen use was not documented routinely to show how much oxygen the resident was on, as well as when and why the resident's oxygen use was increased/decreased and the resident's response to the changes. On 12/21/23 at 1551 hours, an interview was conducted with the DON. The DON stated supplemental oxygen use should be documented in the MAR and daily Skilled Evaluation charting. The DON stated there was a section specifically for supplemental oxygen use and the nurses should be completing that section for all residents with supplemental oxygen. 3. Medical record review for Resident 4 was initiated on 12/20/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary report dated 12/21/23, showed a physician's orders dated 12/11/23, for the supplemental oxygen to be administered at 2-5 lpm PRN for shortness of breath to keep the oxygen blood saturation levels above 93%. Review of Resident 4's Medication Administration Record for December 2023 showed the PRN oxygen was administered on 12/21/23 at 0907 hours. There was no other documentation on the administration record to show the prior supplemental oxygen was administered. 055575 Page 8 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0842 Level of Harm - Potential for minimal harm Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/12/23 at 0429 hours, showed Resident 4 was on room air. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/13/23 at 0052 hours, showed Resident 4 was on supplemental oxygen at 2 lpm. Residents Affected - Some Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/14/23 at 0200 hours, showed Resident 4 was on room air. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/15/23 at 0036 hours, showed Resident 4 was on supplemental oxygen via nasal canula. The oxygen rate was not documented. Review of Resident 4's Health Status Note dated 12/15/23 at 1230 hours, showed Resident 4 was on supplemental oxygen at 2 lpm. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/16/23 at 0047 hours, showed Resident 4 was on supplemental oxygen via nasal canula. The oxygen rate was not documented. Review of Resident 4's Health Status Note dated 12/16/23 at 1752 hours, showed Resident 4 was on supplemental oxygen at 3 lpm. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/17/23 at 0259 hours, showed Resident 4 was on supplemental oxygen at 2 lpm. Review of Resident 4's Health Status Note dated 12/17/23 at 1245 hours, showed Resident 4 was on supplemental oxygen at 3 lpm. Review of Resident 4's Health Status Note dated 12/17/23 at 1245 hours, showed Resident 4 was on supplemental oxygen at 3 lpm. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/82/23 at 0031 hours, showed Resident 4 was on room air. Review of Resident 4's Health Status Note dated 12/18/23 at 0715 hours, showed Resident 4 was on supplemental oxygen at 3 lpm. Review of Resident 4's Health Status Note dated 12/18/23 at 1003 hours, showed Resident 4 was on supplemental oxygen at 3 lpm. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/19/23 at 0056 hours, showed Resident 4 was on supplemental oxygen via nasal canula. The oxygen rate was not documented. Review of Resident 4's N Adv – Skilled Evaluation V6.3 dated 12/20/23 at 0003 hours, showed Resident 4 was on supplemental oxygen at 3 lpm. On 12/21/23 at 1355 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 4 had a physician's order for oxygen to be administered at 2-5 lpm as needed for shortness of breath. LVN 2 verified the record showed Resident 4 was on room air, as well as oxygen at 2 and 3 lpm without documentation to show the time and reason for changes in oxygen 055575 Page 9 of 10 055575 12/22/2023 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some administered, the resident's response to the treatment, and the duration of the treatment. LVN 2 reviewed Resident 4's MAR and verified the MAR did not show supplemental oxygen was administered and should be documented. LVN 2 stated they took care of resident 4 last week and recalled the resident being on oxygen. On 12/21/23 at 1551 hours, an interview was conducted with the DON. The DON stated the supplemental oxygen use should be documented in the MAR and daily Skilled Evaluation charting. The DON stated there was a section specifically for supplemental oxygen use and the nurses should be completing that section for all residents with supplemental oxygen. 4. Closed medical record review for Resident 1 was initiated on 12/20/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/4/23. Review of Resident 1's physician's orders showed an order dated 11/28/23, for continuous supplemental oxygen to be administered at 2-5 lpm. Review of Resident 1's COMS – Clinical admission Evaluation dated 11/28/23 at 2025 hours, showed Resident 1 was on 3 lpm supplemental oxygen. Review of Resident 1's N Adv – Skilled Evaluation V6.3 dated 11/29/23 at 1956 hours, showed the resident was oxygen at 2 lpm. Review of Resident 1's N Adv – Skilled Evaluation V6.3 dated 12/1/23 at 1859 hours, showed the resident was on supplemental oxygen, but did not include the flow rate. Review of Resident 1's N Adv – Skilled Evaluation V6.3 dated 12/2/23 at 1806 hours, showed the resident was on supplemental oxygen at 2lpm. Review of Resident 1's N Adv – Skilled Evaluation V6.3 dated 12/3/23 at 1750 hours, showed the resident was on supplemental oxygen at 2 lpm. On 12/21/23 at 1502 hours, a concurrent interview and closed medical record review was conducted with LVN 2. LVN 2 verified Resident 1 had a physician's order for continuous oxygen to be administered at 2-5 lpm. LVN 2 verified the medicalrecord showed Resident 1 was on oxygen at 3 lpm, then decreased to 2 lpm, without documentation to show the time and reason the oxygen was adjusted and the resident's response to the treatment. 055575 Page 10 of 10