Health inspection·June 8, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) quarterly assessments were completed timely for 3 of 4 residents reviewed for Resident Assessments from a total sample of 46 residents, (#74, #84, #103) Residents Affected - Few Findings: 1. Review of the medical record revealed resident #74 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of pressure ulcer of the right heel, dysphagia (swallowing difficulty), presence of gastrostomy (tube feeding device), peripheral vascular disease (poor circulation to extremities), muscle contractures, dementia, depression, and malnutrition. Review of the MDS quarterly assessment with Assessment Reference Date (ARD) 5/24/2023 showed it was in progress and due for completion on 6/07/2023. 2. Review of the medical record revealed resident #84 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses of repeated falls, viral hepatitis, severe kidney disease, heart disease, weakness, cognitive communication deficit, and difficulty in walking. Review of the MDS quarterly assessment with ARD 5/20/2023 showed it was in progress and due for completion on 6/03/2023. 3. Review of the medical record revealed resident #103 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of liver transplant, renal dialysis dependence, kidney failure, history of falls, depression, anxiety, weakness, need for assistance with personal care, and anemia. Review of the MDS quarterly assessment with ARD 5/18/2023 noted it was completed late on 6/6/2023. Review of the MDS 3.0 Final Validation Report dated 6/06/2023 noted a message for resident #103's 5/18/2023 assessment that read, Assessment Completed Late . Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). On 6/07/2023 at 4:20 PM, the Director of Nursing (DON) stated the facility had been short staffed for MDS Coordinators since approximately April 2023 when the full-time coordinator left. She said there was one part time person, and she was not working on 6/07/2023 or 6/08/2023. She explained the facility received additional support on occasion from a traveler MDS Coordinator. She said she was responsible for the department and an additional full-time nurse was planned to start soon. On 6/08/2023 at 1:52 PM, the DON checked the medical record and acknowledged the MDS assessments were overdue and not completed yet, or had been completed late. She said she had been informed by corporate management there were multiple late MDS assessments. The facilities policies and procedures dated 3/27/2018 titled, SHCO40001.01 Resident Assessment Process, read, 13. The MDS completion date (Z500B) must be within 14 days of the Assessment Reference Date (ARD) (A2300) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 2 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessment related to functional range of motion (ROM) for 1 of 1 resident reviewed for mobility, of a total sample of 46 residents, (#55). Residents Affected - Few Findings: Resident #55, a 68- year-old female was admitted to the facility on [DATE] with diagnoses which included stroke, contractures of her left upper extremity, and generalized muscle weakness. The resident's admission, and modification to admission MDS assessment with Assessment Reference date of 2/24/23, revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 13 out of 15. Resident #55 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and required one person assistance for eating. The assessment indicated the resident had no impairment in functional limitation in range of motion of her upper and lower extremities. On 6/05/23 at 10:15 AM, resident #55 was sitting up in bed, her left hand was contracted, and the resident was not wearing a splint/brace. A palm guard was noted on the bedside table. Resident #55 stated she had two strokes and could not move her left arm or hand. On 6/07/23 at 12:56 PM, Licensed Practical Nurse (LPN) D confirmed the resident had a contracture of her left upper extremity and stated therapy had been working with the resident for the contracture, but the resident had been refusing splint placement. On 6/07/23 at 2:36 PM, the Rehab Program Manger stated resident #55 had a contracture of her left hand/arm, but the resident would not allow therapy to do much ROM and had refused all splinting. On 6/08/23 at 1:20 PM, the resident's clinical records were reviewed with the Regional Clinical Services Director, and she confirmed the resident's admitting diagnoses included contracture of her left upper extremity. On 6/08/23 at 1:43 PM, the Director of Nursing (DON) stated the facility had a part time MDS Coordinator who was currently unavailable. The resident's clinical records, her admission and modification of admission MDS assessments were reviewed with the DON. She stated the resident had limitation in her ROM due to the contracture. The DON acknowledged section G0400 on the admission MDS assessment was not accurate. The Centers for Medicare & Medicaid Services Long-term Care Facility Resident Assessment Instrument 3.0 user's manual Version 1.17.1 dated October 2019, defines Functional limitation in range of motion as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. The manual indicated that assessment would be Coded 0 no impairment: if resident has full functional range of motion on the right and left side of upper/lower extremities. Resident #55 had contracture of the muscles of her left upper extremity, and contracture of unspecified joint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 3 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to review and revise care plans to meet the residents' need pertaining to activities for 3 of 3 cognitively impaired residents reviewed for activities, of a total sample of 46 residents, (#17 #20 #74). Findings: 1. 1. Resident #17, a [AGE] year-old female was admitted to the facility originally on 8/14/22 and readmitted on [DATE]. Her diagnoses included mood disorder, schizoaffective disorder, anxiety disorder. schizophrenia, dementia, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/18/23 revealed the resident's cognition was not assessed. The assessment revealed the resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:37 AM, and on 6/06/23 at 11:16 AM, resident #17 was lying on her back in a low bed. The resident did not respond when spoken to. The resident's television was not on, no music was playing, and no form of activity was noted for the resident. On 6/08/23 at 11:16 AM, the Activities Director stated care plans for activities were developed, reviewed/revised by the Activities Director. The resident's care plan for activities initiated on 8/22/22 and revised on 3/02/23 was reviewed with the Activities Director. She confirmed the goal of the care plan was for the resident to continue to make their choices regarding activities and express satisfaction on their activities of choice. Interventions included honor resident right to choose programs of own liking daily .including self-directed. Provide resident with alternative choices for self-directed/non- organized activities. Provide with a life enrichment programming calendar to encourage self-direction when choosing daily activities. The Activities Director stated the resident's cognition was moderately impaired. She acknowledged the care plan interventions were not individualized, or person centered since the resident could not do self-directed activities or choose activities from the activity calendar. 2. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses which included dementia, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder. Review of the resident's quarterly MDS assessment with ARD of 5/02/23, revealed the resident's cognition was rarely/never understood. The assessment revealed the resident required extensive assistance of two persons for transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:32 AM, and on 6/06/23 at 10:45 AM, resident #20 was lying in bed. There was no response when spoken to, and no activities were noted. The television was not on and there was no music playing in the room. On 6/06/23 at 4:16 PM, Certified Nursing Assistant (CNA) C stated resident #20 required total care for all her activities of daily living and could not make her needs known. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 4 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/07/23 at 1:03 PM, and at 2:28 PM, the Activities Director stated that a care plan for activities would be initiated as soon as a resident was admitted . She explained interventions initiated would be dependent on the MDS assessment. The Activities Director stated she conducted an audit in April 2023 to identify mental status and communication needs of residents. She noted resident #20 had severe cognitive impairment, was never /rarely understood. The resident's care plan for activities initiated 11/05/22 and revised on 11/09/22 was reviewed with the Activities Director. Interventions included, assist with arranging community activities, introduce to residents with similar background, interests, and encourage/facilitate interaction. The Activities Director said the care plan was not person centered or individualized since the resident was unable to do any self-directed activities or choose activities from the activity calendar. 3. Resident #74, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included dementia, dysphagia, acute respiratory failure with hypoxia, and gastrostomy. Review of the resident's quarterly MDS assessment with ARD of 2/02/23 revealed the resident was rarely/never understood. Resident #74 was totally dependent on staff for bed mobility, transfers, toilet use, and required extensive assistance of two persons for dressing. On 6/05/23 at 10:32 AM, resident #74 was lying in bed, with her eyes closed. There was no response when spoken to. On 6/06/23 at 10:43 AM, the resident was lying in bed with her eyes open. There was no response when spoken to. The television was not on, no music or any other activities were observed in the resident's room. On 6/07/23 at 1:03 PM, and at 2:28 PM, the Activities Director stated she reviewed resident #74's care plan for activities on 5/30/23 , and no significant changes were identified so a revision of her activities care plan was not done. The residents' care plan for activities was reviewed with the Activities Director. She verbalized the resident's care plan was initiated prior to her hire date, and since she had been hired, she had not reviewed or revised the activities care plan. The care plan interventions included honor resident right to choose programs of own liking daily .including self-directed. Provide resident with alternative choices for self-directed/non- organized activities. Provide with life enrichment programming calendar to encourage self-direction when choosing daily activities. The Activities Director said the care plan was not person centered and individualized since resident #74 could not do self-directed activities or choose activities from the activity calendar. The facility policy Comprehensive Person-Centered Care Plans with revised date of 8/31/2022, and effective date of 10/24/2022, read, The center will develop a comprehensive person-centered care plan for each resident that is individualized and includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. the document indicated the care plan would be Reviewed and revised by the interdisciplinary team after each assessment .and as changes in the resident's care and treatment occur FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 5 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an ongoing program of activities was provided for 3 of 3 cognitively impaired residents reviewed for activities, of a total sample of 46 residents, (#17 #20 #74). Residents Affected - Few Findings: 1. Resident #17, a [AGE] year-old female was admitted to the facility originally on 8/14/22 and readmitted on [DATE]. Her diagnoses included mood disorder, schizoaffective disorder, anxiety disorder, schizophrenia, dementia, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/18/23 revealed the resident's cognition was not assessed. The assessment revealed the resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:37 AM, and on 6/06/23 at 11:16 AM, resident #17 was lying on her back in a low bed. The resident did not respond when spoken to. The resident's television was not on, no music was playing, and no form of activity was noted for the resident. Review of the resident's Point of Care Response History record from 5/10/23 to 6/07/23 revealed the resident refused one to one activities on 5/27/23. The records showed the resident actively participated in conversation and talking during activities on 5/09/23, 5/10/23, 5/11/23, 5/13/23, 5/15/23, 5/16/23, 5/17/23, 5/20/23, 5/25/23, and 5/27/23. Not applicable was selected for activities on 5/19/23,5/20/23, 5/25/23, and 5/26/23 2. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses which included dementia, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder. Review of the resident's quarterly MDS assessment with ARD of 5/02/23, revealed the resident's cognition was rarely/never understood. The assessment revealed the resident required extensive assistance of two persons for transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:32 AM, and on 6/06/23 at 10:45 AM, resident #20 was lying in bed. There was no response when spoken to, and no activities were noted. The television was not on and there was no music playing in the room. On 6/06/23 at 4:16 PM, Certified Nursing Assistant (CNA) C stated resident #20 required total care for all her activities of daily living and could not make her needs known. Review of the resident's Point of Care history log from 5/10/23 to 5/27/23 revealed no documentation for one to one activity visits. The log showed the resident actively participated in conversation and talking activities on 5/10/23, 5/11/23, 5/12/23, 5/16/23, 5/17/23, 5/23/23, 5/25/23, and 5/27/23. No other documentation could be identified regarding activities for resident #20. 3. Resident #74, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 6 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 included dementia, dysphagia, acute respiratory failure with hypoxia, and gastrostomy. Level of Harm - Minimal harm or potential for actual harm Review of the resident's quarterly MDS assessment with ARD of 2/02/23 revealed the resident was rarely/never understood. Resident #74 was totally dependent on staff for bed mobility, transfers, toilet use, and required extensive assistance of two persons for dressing. Residents Affected - Few On 6/05/23 at 10:32 AM, resident #74 was lying in bed, with her eyes closed. There was no response when spoken to. On 6/06/23 at 10:43 AM, the resident was lying in bed with her eyes open. There was no response when spoken to. The television was not on, no music or any other activities were observed in the resident's room. Review of the resident's Point of Care record from 5/10/23 to 5/31/23 noted the resident refused one to one activity visit on 5/27/23. The record showed the resident actively participated in conversation and talking activities on 5/10/23, 5/11/23, 5/12/23, 5/13/23, 5/16/23, 5/17/23, 5/19/23, 5/23/23, 5/25/23, and 5/27/23. The activities staff had noted Observation on 5/09/23, and 5/19/23, and Not applicable was selected on 5/23/23, and 5/31/23. No additional documentation could be identified for activities for resident #74. Review of the Activities Calendar for January 2023 to June 2023 showed one-to-one visits were scheduled for every Monday and Thursday. Review of the one-to-one log revealed resident #17 was not on the log, resident #20 had one one-to-one visit on 1/12/23, and resident #74 had one one-to-one visit on 2/09/23. The Activities calendars, and the one-to-one logs were reviewed with the Activities Director. She acknowledged the documentation. On 6/07/23 at 1:03 PM, and on 6/08/23 at 11:00 AM, the Activity Director stated she conducted an audit in April 2023 to identify the mental status and communication needs of residents. She stated that from the audit, it was identified that residents #17, #20, and #74 had severely impaired cognition and the residents were never/rarely understood. She recalled that based on the audit, she had to revise the activities calendar and add activities for residents who were cognitively impaired. This included weekly one-to-one visits for all cognitively impaired residents on Mondays and Wednesdays, and sensory group activity twice monthly. She stated the one to one log was completed by the Activities Assistant, along with daily visits, which would be documented in the residents' Point of Care Response History. She acknowledged there was no documentation to confirm one-to-one visits were provided for the residents as scheduled on the activity calendars. The Activities Director stated that from documentation reviewed, weekly one-to-one visits were not done for residents #17, #20, and #74. The residents Point of Care Response History was reviewed with the Activities Director. She explained that morning rounds were conducted by the Activity Assistant, and they were directed to talk with residents, and read the daily news provided in Spanish and English. She explained that Active indicated the resident actively participated in the activity, and passive indicated staff performed the activity. The Activity Director explained passive response would apply to residents with severely impaired cognition. She stated residents #17, #20, and #74's cognition was severely impaired and they could not comprehend the news. She said the documentation on the Point of Care record indicated the residents actively participated in the task which was not correct. She noted the Activity Assistant should have selected, passive participation which would have been appropriate for residents #17, #20 and #74. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 7 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm The facility's policy Activity Program revised on 6/26/2018 indicated the facility would provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial wellbeing of each resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 8 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkview Rehabilitation Center at Winter Park 2075 Loch Lomond Drive Winter Park, FL 32792 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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, and record review, the facility failed to ensure Oxygen (O2) therapy was administered at the correct flow rate per physician's order for 1 of 2 residents reviewed for oxygen, of a total sample of 46 residents (#104). Residents Affected - Few Findings: Resident # 104 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), dementia, psychotic disorder with hallucinations, diabetes type II, major depressive disorder, and Alzheimer's disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 4/07/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status score of 03 out of 15. Resident #104 had total dependence on staff of two persons for transfers and required extensive assistance of two persons for bed mobility, toilet use, personal hygiene, and dressing. The assessment revealed the resident received oxygen therapy. Review of the resident's physician's order revealed an order dated 10/03/23 for oxygen at 2 Liters per minute (LPM) continuously via nasal cannula every shift for COPD. On 6/05/23 at 10:25 AM, and at 1:16 PM resident #104 was lying in bed on her back, O2 therapy was infusing at 3 LPM via nasal cannula. On 6/05/23 at 2:09 PM, Licensed Practical Nurse (LPN) A stated resident #104 was on 02 as needed. The resident's physician orders were reviewed with the LPN and revealed an order for 02 continuously at 2 LPM every shift. Observation of the O2 flow rate for resident #104 was conducted with LPN A. She confirmed O2 was infusing at 3 LPM instead of 2 LPM as ordered by the physician. The LPN stated O2 was adjusted by nurses and was checked during medication administration. She said she checked the resident's O2 therapy this morning, and thought it was on 2 LPM. On 6/05/23 at 2:13 PM, Unit A LPN/Unit Manager stated O2 administration was by physician order, and nurses should be checking O2 every shift. She stated the expectation was that O2 was to be administered per the physician's order. On 6/06/23 at 4:25 PM, the Director of Nursing (DON), said nurses were expected to follow the physician order for flow rate for residents on O2 therapy, and nurses were expected to check on the resident's O2 therapy every shift, or if there were any changes with the resident. The resident's care plan Oxygen therapy related to impaired gas exchange, COPD, initiated on 3/31/23 with revision on 4/17/23 interventions included Oxygen therapy as per MD (Medical Doctor) orders 5/23/23 Oxygen via nasal cannula 2 liters/COPD. The facility's policy Oxygen Administration revised on 5/22/2018 instructions included, Check physician's order Turn the unit on to the desired flow rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105307 If continuation sheet Page 9 of 9