Inspection·October 5, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, staff interview, police report review, and facility self-reported incident (SRI) review the facility failed to ensure Resident #43 was free from misappropriation. This affected one resident (#43) out of twenty-one residents reviewed for misappropriation of property. The facility census was 60. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, major depressive disorder, and type two diabetes. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely impaired cognitively and exhibited disorganized thinking and altered level of consciousness behaviors which fluctuated. Resident #43 required limited assistance from one staff member for completion of his activities of daily living. Review of facility SRI tracking number (#) 231572 dated 01/29/23 revealed Resident #43's daughter reported to the nurse that her father's debit card was stolen from his wallet and someone was using it. Review of the police report titled Investigative Report Supplement, dated 01/29/23, incident #23-0001124, revealed Detective #703 spoke with Resident #43's daughter, who stated her father's debit card was being used. She stated on 01/29/23 there were purchases made in [NAME], Ohio at Target for 5.95 dollars, Pandora for 80.00 dollars, and Buffalo Wild Wings for 15.78 dollars. There were also purchases made at [NAME] Wireless for 66.00 dollars and a Shell station for ten dollars. On 01/30/23 Resident #43's daughter stated to Detective #703 on 01/28/23 unknown persons attempted to make online transactions with the card at Amazon, CashApp, and T-Mobile; however, they were unsuccessful due to the person not having the proper security codes. Review of the police report titled Investigative Report Supplement, dated 03/16/23, incident #23-0001124, revealed on 02/07/23 Group Home Supervisor #701, where Hospitality Aide #700 resided, was shown video evidence of the fraudulent transactions by Detective #704, which Group Home Supervisor #701 confirmed was completed by Hospitality Aide #700. When asked about the debit card by Detective #704, Hospitality Aide #700 claimed to have found the card on the ground and had not stolen it from Resident #43. Hospitality Aide #700 stated to Detective #704 she no longer was in possession of the card. Guardian #702 was informed by Detective #704 of Hospitality Aide #700's case and was made aware criminal charges would be forthcoming. Interview on 10/03/23 at 8:18 A.M. with Resident #43 confirmed his credit card had been stolen and someone used it. He stated they found the person, and there was a court case. Interview on 10/05/23 at 9:28 A.M. with the Director of Nursing (DON) stated the police had brought in a jump drive of videos of Hospitality Aide #700 using Resident #43's debit card for her to view. The DON stated she saw Hospitality Aide #700 in those videos using Resident #43's card in Target and Starbucks and confirmed she had taken Resident #43's debit card. The DON stated Resident #43's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 2 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0602 bank had either reimbursed or stopped payment for items purchased with card. Level of Harm - Minimal harm or potential for actual harm Review of personnel file for Hospitality Aide #700 revealed a hire date of 01/16/23. Hospitality Aide #700 was terminated 02/02/23 because the criminal background check, completed by the Ohio Bureau of Criminal Investigation, showed criminal charges of theft. Residents Affected - Few The deficient practice was corrected on 02/13/23 when the facility implemented the following corrective actions: • Resident #43 was reimbursed on 01/29/23. • All staff were re-educated on the Abuse Prohibition Policy on 1/30/23. • Hospitality Aide #700 was terminated 02/02/23. • On 02/03/23, the DON interviewed interviewable residents who were on the same hallway, and no other residents voiced concerns of misappropriated property. • On 02/06/23, the police shared the video footage with the facility which also confirmed it was Hospitality Aide #700 using Resident #43's debit card. • Beginning on 02/13/23 the DON/Designee randomly interviewed three staff members from all departments three times a week for three weeks on the Abuse Prohibition Policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 3 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, staff interview, police records review, self-reported incident (SRI) review, and facility policy review the facility failed to ensure their abuse policy was implemented to prevent staff misappropriation of property from Resident #43. This affected one resident (#43) of twenty-one residents reviewed for abuse, neglect, and misappropriation. The facility census was 60. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, major depressive disorder, and type two diabetes. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely impaired cognitively and exhibited disorganized thinking and altered level of consciousness behaviors which fluctuated. Resident #43 required limited assistance from one staff member for completion of his activities of daily living. Review of facility SRI tracking number (#)231572 dated 01/29/23 revealed Resident #43's daughter reported her father's debit card was stolen from his wallet and someone was using it. Interview on 10/03/23 at 8:18 A.M. with Resident #43 confirmed his credit card (debit) was stolen and someone used it. He stated they found the person, and there was a court case. Interview on 10/05/23 at 9:28 A.M. with the Director of Nursing (DON) verified their policy was not implemented as the video evidence brought in by Detective #704 on 02/06/23 confirmed Hospitality Aide #700 had taken Resident #43's debit card and used it to purchase items at Target and Starbucks. Review of the police report related to SRI #231572 revealed on 02/07/23 Group Home Supervisor #701, where Hospitality Aide resided, was shown video evidence by Detective #704 of fraudulent transactions, which Group Home Supervisor #701 confirmed was Hospitality Aide #700. When asked about the debit card by Detective #704, Hospitality Aide #700 claimed to have found the card on the ground and had not stolen it from Resident #43. Hospitality Aide #700 told Detective #704 she no longer was in possession of the card. Guardian #702 was informed by Detective #704 of Hospitality Aide #700's case and was made aware criminal charges would be forthcoming. Review of personnel file for Hospitality Aide #700 revealed a hire date of 01/16/23. Hospitality Aide #700 was terminated 02/02/23 because the criminal background check, completed by the Ohio Bureau of Criminal Investigation, showed criminal charges of theft. Review of the facility policy titled Abuse Prohibition, revised 06/27/23, revealed residents would be free of misappropriation, the deliberate wrongful use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 02/13/23 when the facility implemented the following corrective actions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 4 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0607 • Level of Harm - Minimal harm or potential for actual harm Resident #43 was reimbursed on 01/29/23. • Residents Affected - Few All staff were re-educated on the Abuse Prohibition Policy on 1/30/23. • Hospitality Aide #700 was terminated 02/02/23. • On 02/03/23, the DON interviewed interviewable residents who were on the same hallway, and no other residents voiced concerns of misappropriated property. • On 02/06/23, the police shared the video footage with the facility which also confirmed it was Hospitality Aide #700 using Resident #43's debit card. • Beginning on 02/13/23 the DON/Designee randomly interviewed three staff members from all departments three times a week for three weeks on the Abuse Prohibition Policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 5 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #15 revealed an admission date of [DATE]. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), colitis, and osteoarthritis. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. He required total assistance of two people for bed mobility, transfers and toilet use, total assistance of one person for hygiene, extensive assistance of one person for dressing, and limited assistance of one person for eating. He was on oxygen. Review of the physician's orders for [DATE] revealed an order for three liters of oxygen continuously. Review of Resident #15's care plan dated [DATE] revealed nothing related to oxygen use or respiratory care. Interview on [DATE] at 4:01 P.M. with LPN #520 confirmed oxygen had not been addressed in Resident #15's care plan. Review of the facility policy titled Care Plans-Comprehensive, dated [DATE], revealed each resident's comprehensive care plan would be designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. Assessments of the residents would be ongoing and care plans would be revised as information about the resident and the resident's condition changed. The Care Planning/Interdisciplinary team would be responsible for the review and updating of care plans. Based on medical record review, staff interviews, and facility policy review the facility failed to develop comprehensive care plans for Residents #15, #56, #60, and #67. This affected four residents (#15, #56, #60, and #67) out of 20 residents reviewed for care plans. The facility census was 60. Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of [DATE]. Diagnoses included acute respiratory failure with hypoxia, anoxic (deficient in oxygen) brain damage, dysphagia (difficulty swallowing), persistent vegetative state, type two diabetes, and dependence on respirator status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was in a persistent vegetative state with no discernible consciousness; required total dependence on two persons for all activities of daily living; was on oxygen; needed suctioned; had a tracheostomy and used an invasive mechanical ventilator. Review of the care plan for Resident #60, initiated on [DATE], revealed there was no care plan for his tracheostomy. Interview on [DATE] at 8:20 A.M. with Registered Nurse (RN) #506 regarding Resident #60's care plan confirmed there should have been a care plan for his tracheostomy, but there was not one. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 6 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0656 stated it was due to a lack of oversight. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #67 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, and hyperkalemia (high potassium levels in blood). Residents Affected - Some Review of the admission/Medicare five-day MDS assessment revealed Resident #67 had moderate cognitive impairment; required extensive assistance of two persons for bed mobility, total dependence of one person for locomotion, dressing, eating, toilet use, and personal hygiene, total dependence of two persons for transfers; and was on dialysis. Review of the progress note dated [DATE] revealed Resident #67 had expired in the facility. Review of the facility document Record of Discharge/Expiration revealed a final diagnosis of End Stage Renal Disease (ESRD), and his cause of death was from ESRD. Review of the care plan initiated [DATE] revealed there was no care plan for dialysis. Interview with Corporate Registered Nurse (RN) #706 on [DATE] at 4:01 P.M. confirmed there should have been a care plan for dialysis for Resident #67, but there was not one.3. Review of the medical record for Resident #56 revealed an admission date of [DATE], medical diagnoses included Alzheimer's disease with late onset and saddle embolus of pulmonary artery with acute cor pulmonale. Review of the physician orders for Resident #56 revealed an order [DATE] to take coumadin (anticoagulant) 3 milligrams (mg) by mouth daily at 10:00 P.M. Review of the care plan dated [DATE] for Resident #56 revealed the care plan did not include that Resident #56 took an anticoagulant. Interview with LPN #520 on [DATE] at 3:22 P.M. confirmed Resident #56's care plan did not reflect that the resident took an anticoagulant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 7 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed prevent a fall with injury for Resident #20. Actual Harm occurred on 07/13/23 when Resident #20 who required extensive assistance of one person for bed mobility, did not have fall prevention interventions in place, fell from bed and sustained large left periorbital and front scalp hematomas (an injury that causes blood to collect and pull under the skin) and a fracture involving the left orbital roof extending into the left frontal sinus. This affected one resident (#20) of three residents reviewed for falls. The facility census was 60. Findings include: Review of the medical record for Resident #20 revealed an admission date of 11/28/22 with diagnosis including diabetes, kidney failure, heart disease, and dementia. Review of the fall risk evaluation dated 05/23/23 revealed Resident #20 was at risk for falls. Review of the care plan dated 06/26/23 revealed Resident #20 was at risk for falls due to confusion, incontinence, and balance problems. Interventions included a falling star magnet on the doorway to alert staff to risk of frequent falls, a fall mat to the open side of the bed when the resident was in bed, and the bed was to be against the wall and in the lowest position when in the resident was in bed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. The assessment revealed the resident required extensive assistance of two people for transfers and toilet use, extensive assistance of one person for bed mobility, dressing, and hygiene and supervision of one person for eating. The MDS revealed the resident had sustained one fall since the previous assessment. Review of a progress note dated 07/13/23 and timed 10:04 P.M. revealed Resident #20 was calling out when the State Tested Nursing Assistant (STNA) and nurse walked into her room and found her on the floor. The (resident's) bed was at hip level and there was no fall mat on the floor. Resident #20 had a hematoma noted to her left eye, small skin tears to her right arm and left knee, and her right knee appeared swollen. Vitals were obtained and the resident was transferred to the Emergency Department (ED) via 911. Review of the hospital paperwork dated 07/14/23 revealed Resident #20 was treated for an unwitnessed fall from her bed. She had a hematoma above her left eye, abrasions on her left leg, and a bruise to her left upper lip. An x-ray of her left knee was obtained with no fracture identified and a computerized tomography (CT) scan of the head was completed with large left periorbital and front scalp hematomas discovered. Review of the fall investigation dated 07/14/23 revealed Resident #20 was observed on the floor in her room. She had a large hematoma to her left eye and a skin tear to her arm and leg. She was sent to the ED for evaluation. She was being treated for a urinary tract infection (UTI) at the time. The investigation revealed the resident had multiple interventions due to previous falls. However, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 8 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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 0689 there was no mat to the left side of her bed and her bed was not in the lowest position. The Treatment Administration Record (TAR) revealed the nurse had verified the interventions were in place. Level of Harm - Actual harm Residents Affected - Few Interview on 10/04/23 at 2:36 P.M. with Licensed Practical Nurse (LPN) #515 revealed on 07/13/23 she and the agency STNA she was working with heard yelling which sounded like Resident #20. They went to her room and found her lying on the floor, her bed was at hip level, and there was no fall mat on the floor which was an ordered intervention. She revealed she told the agency STNA earlier in the shift to make sure they (the fall mat and bed in low position) were in place earlier, but she must not have. The resident was flat on her back and her face was bruised. She put a pillow under the resident's head while the STNA stayed with the resident, and called the family, the physician, and 911. She took the resident's vital signs, and her blood pressure was elevated. She revealed a hematoma over her left eye developed quickly, but she never lost consciousness. The LPN could not recall if the resident could tell her what she was doing, but stated she was often confused. LPN #515 revealed staff needed to do better about ensuring interventions were in place. She revealed she was not asked to complete a witness statement as part of a fall investigation, just a fall report. Interview on 10/05/23 at 9:42 A.M. with the Director of Nursing (DON) confirmed the investigation of the fall for Resident #20 revealed fall interventions were not in place at the time of the fall. If the fall interventions had been in place, Resident #20 may not have sustained the injuries she did. Review of the facility policy titled Falls Reduction Policy, dated 01/01/15, revealed the facility would put interventions in place to reduce falls and minimize the risk of injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 9 of 10 Printed: 05/15/2026 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 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 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, record review, and facility policy review the facility failed to administer oxygen to Resident #15 as ordered by the physician. This affected one resident (#15) of three residents review for respiratory care. The facility census was 98. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 10/04/18. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), colitis, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. He required total assistance of two people for bed mobility, transfers and toilet use, total assistance of one person for hygiene, extensive assistance of one person for dressing and limited assistance of one person for eating. He was on oxygen. Review of the physician's orders for October 2023 revealed an order for three liters of oxygen continuously. Review of the care plan dated 08/10/23 revealed nothing related to oxygen use or respiratory care for Resident #15. Observation on 10/02/23 at 4:17 P.M. revealed Resident #15's oxygen was in use and set to one liter. Interview on 10/02/23 at the time of the observation with State Tested Nurses Assistant (STNA) #534 confirmed the oxygen tank was set to one liter. Interview on 10/02/23 at 4:19 P.M. with Licensed Practical Nurse (LPN) #513 confirmed the order for Resident #15's oxygen was three liters. She entered Resident #15's room, confirmed the oxygen tank was set at one liter, and adjusted it to the correct setting of three liters. Review of the facility policy titled Oxygen Administration, dated 05/06/15, revealed the facility would review and verify the physician's order prior to oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 10 of 10