Every finding on record at Continuum Home Care & Hospice of Lenior County

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide effective pain management for 1 of 1 patient reporting unmanaged pain (patient #2).Findings included: --- A policy, Pain Assessment and Reassessment (revised 2/2020), received on 6/3/26 at 2:25 PM from the Director of Nursing stated, “When a patient’s pain is not relieved, the nurse will intervene appropriately. Such interventions may include: Notification of the patient’s attending physician and/or Medical Director. Change in pain and symptom management based on physician orders. Patient education regarding alternative pain relief measures… Referral for pain management…”Patient #2 was admitted on 12/24/25 with a diagnosis of hypertensive heart disease (long term unmanaged blood pressure). The plan of care for 3/24/26-6/21/26 included orders for skilled nurse visits 1 time a week for 13 weeks with 3 PRN (as needed) and, “Monitor for effectiveness of pharmacological [medication] and non-pharmacological interventions to achieve comfort.” Review of the clinical record revealed that on 5/20/26 licensed practical nurse (LPN) #12 documented a pain assessment that included; “Primary Location, arms/wrist, Joints, legs/feet. Effect on Quality of Life, Decline in Mood, Decline in physical function. Patient reports, I hurt all the time, voices pain with movement is typically 6-7/10 [pain level at 6-7 on a 1-10 scale]… 1/10 FLACC [non-verbal pain assessment used for non-verbal patients] with movement AEB [as evidenced by] moaning /complaint, reports sharp arthritis pain to joint and nerve pain to BLE [bilateral lower extremities…” Further review revealed that there was no documentation of; a physician being notified for new orders; the registered nurse case manager being notified; a request for the facility nurse to administer a PRN medication; or education of non-pharmacological interventions.During an interview conducted on 6/3/26 at 1:51 PM LPN #12 stated, “I didn’t do anything about the medications, my plan was to reevaluate medication as needed… I’m new…normally I usually try to e-mail or call the nurse case manager.”During an interview conducted on 6/3/26 at 2:39 PM the director of nursing stated, the expectation is for the LPN to, “Report pain to facility staff member, and request that a PRN dose be given, and notify the nurse case manager.”

Based on agency policy, clinical record review, and staff interviews, the interdisciplinary group failed to develop an individualized plan of care for 1 of 1 patient with a documented significant history of urinary tract infections (patient #10).Findings included: --- A policy, Reassessments/Update to the Comprehensive Assessment (revised 2/2021), received on 6/1/26 at 1:55 PM from the Director of Nursing stated, “Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan.”A policy, IDG (Interdisciplinary Group) Care Planning Process (revised 2/20220, received on 6/1/26 at 1:55 PM from the Director of Nursing stated, “The care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions… All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient’s needs…”Patient #10 was admitted on 10/15/25 with a diagnosis of unspecified sequelae of cerebral infarction (lingering effects of a stroke). The plan of care for 4/13/26-6/1/26 included orders for skilled nurse visits 1 time a week for 9 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 5/19/26 nurse practitioner #12 documented, “Patient has a significant history of recurrent UTIs [urinary tract infections], including prior infections severe enough to require hospitalization and IV [intravenous] therapy… each episode results in further decline in cognition and functional status…” Further review revealed that there were no interventions if the plan of care for monitoring for symptoms or education on prevention of UTI’s.An interview conducted on 6/3/26 at 11:27 AM with register nurse case manager #8 revealed that patient #10 should have a plan of care related to recurrent UTIs.An interview conducted on 6/3/26 at 11:29 AM with the director of nursing revealed that the expectation if for an individualized care plan related to UTI’s be included in the plan of care.

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide volunteer visits as ordered in the plan of care for 2 of 2 patients with orders for volunteer visits (patient #5 & 6).Findings included: --- A policy, Professional Standards of Practice (revised 6/20/19), received on 6/1/26 at 1:55 PM from the director of nursing stated, “Hospice staff will provide care, treatment and services to each patient according to the IDG plan of care and physician orders.”1. Patient #5 was admitted on 7/15/25 with a diagnosis of end stage renal disease. The plan of care for 5/11/26-7/9/26 included orders for volunteer visits 3 times a month for 1 month starting 6/1/26 and “Hospice volunteer will provide: companionship, engagement/socialization, supportive listening…”  Review of the clinical record revealed that no volunteer visits were conducted.2. Patient #6 was admitted on 1/13/26 with a diagnosis of chronic obstructive pulmonary disease (lung disease). The plan of care for 4/13/26-6/11/26 included order for volunteer visits 3 times a month for 3 months and “Hospice volunteer will provide: companionship, engagement/socialization, supportive listening…”  Review of the clinical record revealed that no volunteer visits were conducted.An interview conducted on 6/1/26 at 2:53 PM with the volunteer coordinator revealed that the agency does not have any volunteers that conduct home visits.  An interview conducted on 6/2/26 at approximately 2:55 PM with the director of nursing revealed that there may be some confusion related to adding volunteer visit to the plan of care.

Based on agency policy, observation, and staff interviews, the medical social worker (MSW) failed place a barrier under the clinical bag for 1 of 1 patient with a MSW home visit (patient #8) and the registered nurse (RN) failed to perform hand hygiene before removing items from the clinical bag for 1 of 2 patient with a RN home visits (patient #10).Findings included: --- A policy, Professional Standards of Practice (revised 6/2019), received on 6/1/26 at 12:01 PM from the director of nursing stated, “Indications for hand hygiene are: … Before re-entering nursing bag or patient’s clean supplies…”A policy, Exposure Control Plan: OSHA Regulations (revised 6/2019), received on 6/1/26 at 12:01 PM from the director of nursing stated, “Upon entering the home, place the bag on a clean surface. Paper towels or plastic bag may be used to create a clean area if indicated.”1. Patient #8 was admitted on 9/12/24 with a diagnosis of malignant neoplasm of the pancreas (pancreatic cancer). Patient #9 was a resident at a skilled nursing facility. The plan of care for 5/5/26-7/3/26 included orders for MSW visits 2 times a month for 2 months with 3 PRN (as needed). During a home visit conducted on 6/2/26 at 9:00 AM MSW #9 placed the clinical bag on a personal chair without the use of a protective barrier.During an interview conducted on 6/3/26 at 2:54 PM MSW #9 stated, “What I should have done was to put a barrier under the bag.”2. Patient #10 was admitted on 10/15/25 with a diagnosis of unspecified sequelae of cerebral infarction (lingering effects of a stroke). The plan of care for 4/13/26-6/1/26 included orders for skilled nurse visits 1 time a week for 9 weeks with 3 PRN (as needed). Patient #10 was a resident of a skilled nursing facility. During a home visit conducted on 6/2/26 at 9:50 AM RN #3 performed hand hygiene, assessed the patient’s temperature, heart rate, and oxygen saturation and failed to perform hand hygiene before reaching into the clinical bag for supplies.During an interview conducted on 6/3/26 at 2:09 PM RN #3 stated that they normally perform hand hygiene each time they enter the clinical bag.An interview conducted on 6/3/26 at 2:11 PM, with the director of nursing revealed that the expectation is for the clinicians to place a protective barrier under the bag and to sanitize their hands before reaching into the clinical bag.

Based on agency policy, volunteer cost savings review, and staff interviews the agency failed to provide volunteer services to equal 5 percent of patient care hours. Findings included: --- A policy, Volunteer Services (revised 8/25), received on 6/4/26 at 9:18 AM from the Director of Nursing stated, “Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.A review of the volunteer cost savings report revealed that the agency provided volunteer services to equal an average of 0.60% from 6/2025 through 5/2026.An interview conducted on 6/1/26 at 2:53 PM with the volunteer coordinator revealed that they strive to have 5% volunteer to patient care hours.

Based on policy review, clinical record review, and staff interview, the agency failed to document a client concern for 1 of 14 records reviewed (Patient #1). --- Policy 1-010.1, titled ";Complaint/Grievance Process" was received from the agencys quality assurance department on 06/28/23 at 2:40 PM. This policy revealed, ";Any difference of opinion, dispute or controversy between a patient or family/caregiver or patient representative and (agency name) concerning any aspect of services or the application of policies or procedures will be considered a grievance...Complaints will be logged and supportive documentation, including dates, maintained..." Patient #1 was admitted to the agency on 09/26/22 with a primary hospice diagnosis of end stage renal [kidney] disease. Plan of Care from 05/24/23 to 07/22/23 revealed orders for skilled nursing one time per week for one week and two times per week for eight weeks, aide one time per week for one week and two times per week for eight weeks, chaplain one time per month for two months, medical social worker two times per month for two months, and volunteer one time per month for two months. On 06/09/23 at 5:25 PM, Employee #3, Registered Nurse Case Manager, wrote a miscellaneous communication note which stated, ";Notified daughter that x rays of L (left) hand, chest were all negative. She was relieved but did express concern that patient is not being bathed properly. She stated that she stinks..." In an interview on 06/28/23 at approximately 12:00 PM, Employee #3, stated, ";No, because it wasnt a complaint on us, but I just reported it to the director there. Maybe I should have..." regarding reporting or documenting a client concern. In an interview on 06/28/23 at approximately 1:30 PM, Employee #1, Care Manager, stated, ";They still need to report it as a concern/complaint and myself or the Executive Director will handle it."

Based on policy review, clinical record review, and staff interviews the agency failed provide effective pain and symptom control for 2 of 14 patients: (#2, #10): Findings included: --- 1. Patient #2 was admitted on 04/22/2023 with a diagnosis of malignant neoplasm of the bronchus or lung (lung cancer). Patient #2 was a patient at a skilled nursing facility. The plan of care for 04/22/2023-07/20/2023 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks and 3 PRN (as needed) visits. On the SN visit of 04/24/2023 RN #3 stated, ";He stated he had a headache. He was visibly sob [short of breath] on 3 LPM [liters per minute] continuous O2 [oxygen]. Respiratory rate 30s-40s... hypotensive. Spoke to nurse [facility] who stated that the cck [comfort care kit] meds [medications] had not arrived." There was no evidence in the clinical record that the agency used their resources to obtain comfort medications. An interview was conducted with RN #3 on 06/28/2023 at approximately 11:00 A.M. RN # 2 stated, ";I made sure the meds [medications] were ordered and signed by the doctor." An interview was conducted with the Clinical Care Coordinator on 06/28/2023 at 11:45 A.M. The Clinical Care Coordinator stated that the nurse should have contacted our local medical company or a local pharmacy to get the medications quicker. 2. Patient #10 was admitted on 05/11/2023 with diagnoses of cerebrovascular disease (impaired blood flow to the brain), dysphagia (difficulty swallowing), congestive heart failure, and protein calorie malnutrition. Patient # 10 was a patient at a skilled nursing facility. The plan of care for 05/11/2023-08/08/2023 included orders for skilled nurse (SN) visits 2 times a week for 12 weeks and 3 PRN (as needed) visits. On the SN visit of 05/25/2023 RN #3 stated, ";Patient stated she hurt [sic] all the time. Spoke to floor [facility] nurse [nurse name] who stated that she asked for medication as needed." There was no evidence in the clinical record that the agency adjusted the pain medication orders until 06/02/2023. An interview was conducted with RN #3 on 06/28/2023 at approximately 11:00 A.M. RN # 2 stated, ";We changed her oxycodone [pain medication] order on 06/02/2023 to adjust for pain."

Based on agency policy, record review and staff interview the agency failed to obtain orders for medication for 1 of 14 patients (#2); and to obtain orders for wound care for 3 of 5 patients with a wound (#2, 4 and 7); and to obtain orders for indwelling catheter for 1 of 2 patients with indwelling catheter (#14). Findings included: --- 4. Patient #4 was admitted on 5/13/23 with diagnoses of protein-calorie malnutrition and chronic kidney disease. The Plan of Care (POC) for 5/13/23-8/10/23 included orders for skilled nursing visits twice weekly for 13 weeks and 3 as needed for symptom management. The patient resided in a skilled nursing facility (SNF). On 6/14/23, LPN #5 conducted a visit. The LPN identified a skin tear to the left upper arm. The nurses note stated, ";cleansed site and applied a transparent drsg [dressing], notified floor nurse [SNF nurse] of new site and left note for tx nurse [SNF treatment nurse]." An interview with LPN #5 on 6/28/23 at 11:45 a.m. confirmed there was no treatment order for the skin tear. 5. Patient #7 was admitted on 5/8/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 5/8/23-8/2/23 included orders for skilled nursing twice weekly for 13 weeks. The patient resided in a skilled nursing facility. A skilled nursing visit note on 6/23/23 revealed the patient had a dressing on the sacral area (area at the base of the spine). The note stated that it was a ";small maroon" area. There was no evidence wound care orders were obtained. An interview with RN #3 on 6/28/23 at 11:48 a.m. revealed a foam dressing was intact to the area. It also confirmed there was no evidence of wound care orders. A policy, Administration and Documentation of Medications (no date) was received on 06/28/2023 at 11:07 A.M. from the Clinical Care Coordinator. The policy stated, ";[Agency Name] licensed nursing personnel will administer and document only those medications which have been ordered as a part of the Plan of Care." A policy, Physician Orders/Plans of Care (no date) was received on 06/27/2023 at 8:55 A.M. from the Clinical Care Coordinator. The policy stated, ";A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency and duration." 1A. Patient #2 was admitted on 04/22/2023 with a diagnosis of malignant neoplasm of the bronchus or lung (lung cancer). Patient #2 was a patient at a skilled nursing facility. The plan of care for 04/22/2023-07/20/2023 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks and 3 PRN (as needed) visits. On 06/20/2023 RN # 3 documented, ";He [the patient] asked for eye drops, he had some at the bedside, applied drop to both eyes per request." There was no evidence in the clinical record of an order for eye drops." An interview was conducted on 06/27/2023 at approximately 9:30 with RN # 3. RN #3 stated, ";His [patients] wife brought them [eye drops] from home, I should have gotten an order." An interview was conducted on 06/28/2023 at approximately 10:30 A.M with the Clinical Care Coordinator. The Clinical Care Coordinator stated, if they (SN) do not have an order (eye drops), ";we (SN) needed to check with the facility and get an order." 1B. Patient #2 was admitted on 04/22/2023 with a diagnosis of malignant neoplasm of the bronchus or lung (lung cancer). Patient #2 was a patient at a skilled nursing facility. The plan of care for 04/22/2023-07/20/2023 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks and 3 PRN (as needed) visits. On 05/17/2023 RN #3 documented, ";New pressure ulcer to sacrum [area at the base of the spine]. Dressing in place." There was no evidence of an order for a dressing in the clinical record. On 05/23/2023 RN #3 documented that the Stage II wound (pressure injury with a shallow open area) of the patients buttock had healed. An interview was conducted on 06/27/2023 at approximately 9:30 with RN # 3. RN # 3 stated," The sacral and buttock wounds are the same wound." RN # 3 stated, ";I never observed a stage II or any broken skin. It should have been measured and an order documented." An interview was conducted on 06/28/2023 at approximately 10:30 A.M with the Clinical Care Coordinator. The Clinical Care Coordinator stated, ";They [wounds] must be measured weekly, and we [SN] should get the order for wound care." 3. Patient #14 was admitted on 09/15/22 with diagnoses of protein calorie malnutrition and multiple sclerosis (chronic progressive disease involving damage of the nerve cells in the brain and spinal cord). The Plan of Care for 09/15/22-12/12/22 included orders for skilled nurse visits 2 times a week for 12 weeks and home health aide visits 2 times a week for 12 weeks. The clinical record indicated the presence of an indwelling urinary catheter. There was no evidence in the clinical record of an order for the management of the indwelling urinary catheter.

Based on policy review, observation, and staff interviews the agency failed to perform hand hygiene during 1 of 3 staff observations. (#2) Findings included: --- A policy, Surveillance, Prevention and Control of Infections Standard Precautions (no date) was received on 06/28/2023 at 11:07 A.M. from the Clinical Care Coordinator. The policy stated, ";Personnel providing care...will wash their hands...Before and after gloves and other personal protective equipment are used." Patient #2 was admitted on 04/22/2023 with a diagnosis of malignant neoplasm of the bronchus or lung (lung cancer). The plan of care for 04/22/2023-07/20/2023 included orders for skilled nurse visits 2 times a week for 13 weeks and 3 PRN (as needed) visits. A home visit was observed with RN# 3 on 06/27/2023 at approximately 9:00 A.M. RN# 3 provided incontinence care and changed gloves and continued to provide personal care to patient #2. RN # 3 did not perform hand hygiene after removing soiled gloves. An interview was conducted with RN #3 on 06/28/2023 at approximately 9:35 A.M. RN # stated, ";No I didnt wash my hands, but I should have." An interview was conducted with the Clinical Care Coordinator on 06/28/2023 at approximately 10:34 A.M. The Clinical Care Coordinator stated, ";They (all staff) need to wash their hands when entering a room... and between a glove change."

Based on policy review, clinical record review and staff interview, the agency failed to make bereavement services available for 1 of 2 bereavement records reviewed (#13). Findings included: --- A policy, ";Contents of the Clinical Record" (no date), was provided by the clinical care manager on 6/27/23 at 8:55 a.m. The policy stated, ";The contents of the record include...bereavement assessment..." Patient #13 was admitted on 11/3/23 with a diagnosis of Alzheimers disease. The patients date of death was 11/18/23. The ";Bereavement Worksheet" noted the bereavement assessment was initiated on 1/17/23, approximately 2 months post-death. The note stated that the agency was unable to reach the bereaved. There were no other attempts to contact the bereaved. An interview with the medical social worker (MSW) #7 on 6/28/23 at approximately 1:00 p.m. revealed there should have been contact around 12/20/22. An interview with the clinical care manager on 6/28/23 at approximately 1:00 p.m. confirmed there was no evidence of a bereavement assessment until 1/17/23.

Based on policy review, clinical record review, and staff interview, the Hospice Aide failed to follow the aide plan of care for 1 of 14 patients receiving aide services (Patient #8). --- Policy 4-009.1, titled ";Home Hospice Aide Services" was received from the agencys quality assurance department on 06/28/23. This policy revealed, ";These activities (aide services) in accordance with the Interdisciplinary Plan of Care and physicians orders will be assigned and supervised by a Registered Nurse...Hospice Aides will document care provided in accordance with the Hospice Aide Assignment." Patient #8 was admitted to the agency on 02/29/20 with a primary hospice diagnosis senile degeneration of the brain. Plan of care from 04/14/23 to 06/12/23 revealed orders for skilled nursing two times per week for eight weeks, aide three times per week for eight weeks, chaplain one time per month for two months, medical social worker one time per month for one month, two times per month for one month, and one time per month for one month, and volunteer one time per month for three months. Employee #4, hospice aide, conducted a visit on 05/24/23. This visit note revealed, ";Was cutting pt (patient) nails right hand 3rd finger didnt [sic] know that pt nails were curving cut [sic] meat on finger." In an interview on 06/28/23 at 11:30 AM, Employee #4, Hospice Aide, stated that she had cut Patient #8s finger nails and ";I spoke with [(name of facility Director of Nursing(DON))], the nurse on the floor, and [name of agency Licensed Practical Nurse (LPN)]... [name of facility DON] was questioning about did we [sic] or could we cut nails." In an interview on 06/28/23 at 12:00 pm, Employee #1, Care Manager, stated that the Hospice Aides are not to perform tasks that are not part of the care plan and, ";theyre supposed to go their case manager" if a facility staff member requests that the hospice aide perform tasks that are not listed on the aide care plan.

Based on policy review, clinical record review and staff interview, the clinical record did not include a volunteer assessment or plan of care for 5 of 5 patients that had volunteers needs (#4, 7, 9, 1, and 8); and the nurse failed to document a patient incident for 1 of 14 patients (#8). Findings included: --- 4. Patient #1 was admitted to the agency on 09/26/22 with a primary hospice diagnosis of end stage renal [kidney] disease. Plan of Care from 05/24/23 to 07/22/23 revealed orders for skilled nursing one time per week for one week and two times per week for eight weeks, aide one time per week for one week and two times per week for eight weeks, chaplain one time per month for two months, medical social worker two times per month for two months, and volunteer one time per month for two months. Patient #1 received volunteer visits on 01/17/23, 02/21/23, 02/24/23, 03/08/23, 03/21/23, 04/11/23, 04/24/23, and 05/31/23. There was no evidence of a volunteer assessment in the clinical record. 5a. Patient #8 was admitted to the agency on 02/29/20 with a primary hospice diagnosis senile degeneration of the brain. Plan of care from 04/14/23 to 06/12/23 revealed orders for skilled nursing two times per week for eight weeks, aide three times per week for eight weeks, chaplain one time per month for two months, medical social worker one time per month for one month, two times per month for one month, and one time per month for one month, and volunteer one time per month for three months. Patient #8 received volunteer visits on 10/11/22, 11/04/22, 12/16/22, 03/14/23, 04/24/23, and 05/25/23. There was no evidence of a volunteer assessment in the clinical record. In an interview on 06/27/23 at approximately 2:30 PM, Employee # 6 stated that he received notification of patients willing to accept volunteer services and will conduct the patient assessment. Employee #6 also stated, ";No, I havent been doing that (documenting volunteer assessments in the clinical record). 5b. On 05/24/23, Employee #4, Hospice Aide, conducted a visit. This visit note revealed, ";...Was cutting pt (patient) nails right hand 3rd finger didnt [sic] know that pt nails were curving cut meat on finger. Notified Med Tech (Medication Technician)..." In an interview on 06/28/23 at 11:30 AM, Employee #4, stated ";I spoke with [name of facility Director of Nursing (DON)], the nurse on the floor, and [name of agency LPN]... [name of facility DON] was questioning about did we [sic] or could we cut nails." Employee #4 acknowledged that nail cutting was not listed on Patient #8s aide care plan. In an interview on 06/28/23 at 12:10 PM, Employee #5, Licensed Practical Nurse (LPN), stated, that she was aware of the hospice aide cutting Patient #8s fingernails, and that the skin was cut. Employee #4 stated, ";I did not get that documented because that (the incident) was after my visit." In an interview on 06/28/23 at 12:00 pm, Employee #1, Care Manager, stated, ";That should have been reported as an incident." A policy, ";Volunteer Services" (no date) was provided by the clinical care manager on 6/27/23 at 8:55 a.m. The policy stated, ";The volunteer coordinator will develop, implement and evaluate the volunteer services program..." 1. Patient #4 was admitted on 5/13/23 with diagnoses of protein-calorie malnutrition and chronic kidney disease. The Plan of Care (POC) for 5/13/23-8/10/23 orders for ";Volunteer to Assess and Evaluate." The volunteer coordinator conducted visits on 5/25/23 and 6/13/23. There was no evidence of a volunteer assessment or volunteer plan of care. 2. Patient #7 was admitted on 5/8/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 5/8/23-8/2/23 included orders for ";Volunteer to Assess and Evaluate." The volunteer coordinator conducted a visit on 5/25/23. There was no evidence of a volunteer assessment or volunteer plan of care. 3. Patient #9 was admitted on 5/10/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 5/10/23-8/7/23 included orders for ";Volunteer to Assess and Evaluate." The volunteer coordinator conducted a visit on 5/31/23. There was no evidence of a volunteer assessment or volunteer plan of care.

Based on policy review, clinical record review and staff interview, the agency failed to include all physician orders in the clinical record for 2 of 14 patients (#4 and 7). Findings included: --- A policy, ";Physician Orders/Plans of Care" (no date), was provided by the clinical care manager on 6/27/23 at 8:55 a.m. The policy stated, ";The contents of the orders (Plan of Care) will include...A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency and duration...Who is to perform the treatment or procedure...A description of equipment, if any, necessary in the provision of care...A description of any medical, physical, psychosocial or environmental precautions or limitations that affect the implementation of the Plan of Care..." 1. Patient #4 was admitted on 5/13/23 with diagnoses of protein-calorie malnutrition and chronic kidney disease. The Plan of Care (POC) for 5/13/23-8/10/23 included orders for skilled nursing visits twice weekly for 13 weeks and 3 as needed for symptom management. The POC included an order to change indwelling catheter ";as ordered." There was no evidence of an order for the frequency of the change, the catheter size, or balloon size. An interview with RN #5 on 6/28/23 at 11:25 a.m. confirmed there were no specific orders for the indwelling catheter. 2. Patient #7 was admitted on 5/8/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 5/8/23-8/2/23 included orders for skilled nursing twice weekly for 13 weeks; hospice aide twice weekly for 13 weeks; chaplain monthly for three months; medical social worker weekly for 12 weeks; and volunteer to assess and evaluate. The patient resided in a skilled nursing facility. A skilled nursing visit note on 6/12/23 stated, ";Fluid consistency was changed to nectar thickened liquids [due to] patient struggling with egular [sic] liquids." An interview with RN #3 revealed the skilled nursing facility changed the consistency of the liquids. The interview confirmed there was no order in the clinical record.