Health inspection·February 15, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident has a right to a safe, clean, comfortable and homelike environment for one (Resident #7) of 24 residents reviewed for safe and sanitary environment. The facility failed to ensure Resident #7's mattress was free of stain and in good condition. This failure could place residents at risk for an unsanitary and hazardous living conditions. Findings included: Review of Resident #7's admission MDS assessment dated reflected she was a [AGE] year-old female admitted to the facility on [DATE] diagnoses of acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body), arthritis and hip fracture. Resident #7 had a BIMS of 13 indicating she was cognitively intact. Observation and interview on 02/13/24 10:41 AM revealed Resident # 7's mattress had a yellowish/brownish stain on left middle side about 2.5 feet in length by a foot wide. Resident #7 stated she had noticed the stain on her mattress and would like it changed out. She stated it had been like this since she was in the room but was not sure how long that was. Interview on 02/13/24 at 10:47 AM with Housekeeper D revealed she had noticed the stain on Resident #7''s mattress and it should be changed. Follow-up interview on 02/13/24 at 12:25 PM with Housekeeper D revealed she talked to Maintenance Supervisor today about it, but was told by him they had no other new mattresses to replace it with at this time. She stated had been noticing it since Resident #7 was admitted into room but had not talked to anyone about it until today. She stated she noticed the mattress on shower days when bedding was off of it. Observation and interview on 02/13/24 at 12:27 PM with Maintenance Supervisor revealed Resident #7's mattress still had the stain on it. He stated he had been informed by Housekeeper D today about Resident #7 needing a new mattress but he stated could not change it since facility did not have any new mattresses. When surveyor asked him if there were any mattresses in the unoccupied resident rooms, he stated there were empty resident rooms with mattresses and would go see about finding a mattress so he could change Resident #7 's mattress. Review of facility's policy Homelike Environment last revised February 2021 reflected Residents are provided with a safe, clean, comfortable and homelike environment .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment .e. clean bed .that are in good condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 2 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 - Few 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** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 2 (Residents #54 and Resident #44) of 24 residents reviewed for care plans. 1The facility did not develop and implement a comprehensive person-centered care plan to address Resident #54's dependence on indwelling urinary catheter. 2The facility failed to develop a care plan for Resident #44's communication deficit related to diagnoses of aphasia and apraxia. These failures could place resident at risk of not having a plan developed to address care needs. Findings included: 1Resident #54 Review of Resident #54's admission MDS assessment dated [DATE] revealed Resident #54 was [AGE] year-old Female admitted to facility on 10/6/2023. Relevant diagnoses include Cancer, Anemia (Lower amount of healthy red blood cells ), Hypertension (High blood pressure) , Deep vein Thrombosis ( blood clot forms in a deep vein), Neurogenic Bladder (name given to urinary conditions in people who lack bladder control) and Diabetes Mellitus (high blood glucose levels). admission MDS also revealed resident had urinary incontinence and indwelling catheter. Review of admission MDS also revealed Resident #54 had urinary incontinence with Indwelling foley catheter. Review of Resident #54's Comprehensive Care Plan, last updated 10/9/2023, reflected there was no care plan that addressed Resident #54's bowel incontinence and Catheter dependence. Review of Resident #54s Physician order dated 10/17/2023 revealed Catheter - Change bag two times Monthly. Review of Resident #54s Physician order dated 10/17/2023 revealed Catheter - change catheter one time Monthly. Review of Resident #54s Physician order dated 10/17/2023 revealed Catheter - site care by Shift. Review of Resident #54s Physician order dated 10/17/2023 revealed Catheter - change catheter as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 3 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 Review of Resident #54s Physician order dated 10/17/2023 revealed Irrigate catheter as needed. Level of Harm - Minimal harm or potential for actual harm Observation on 2/13/24 10:00 AM revealed Resident #54 had urinary catheter that was hung slightly above the floor and had approximately 500 milliliters urine in it. Residents Affected - Few Interview with Resident #54 on 2/13/24 at10:01 AM revealed that Resident #54 was incontinent with urine and had urinary Catheter since admission to the facility in October. Interview with LVN B on 2/14/24 at 1:34 PM revealed that Resident #54 had urinary catheter bag since admission related to frequent Urinary tract infections. She also revealed that the catheter bag was changed twice monthly, and catheter was changed one time monthly. She also stated that Resident#54s urinary incontinence and Catheter dependence should be care planned, but she was not able to find a care plan on resident #54s electronic health record. Interview with MDS Coordinator on 2/14/24 at 1:49 PM revealed that she had been working in the facility since March 2023. She revealed that she was responsible for care planning chronic conditions for the residents. She stated that Resident #54 had a diagnosis of neurogenic bladder since admission in October 2023 and catheter dependence that should have been care planned. She also stated that care plan issues are identified based on admission MDS. She also stated that risk for not care planning was potential to miss out on patient centered care. Interview with ADON on 2/14/24 at 2:30 PM revealed that the Nurses and herself were responsible for care planning acute conditions whereas MDS coordinator was responsible for care planning chronic conditions. She stated that for Resident #54 Catheter dependence was a chronic issue and should have been care planned during Admission. She stated that risk of not care planning can result in not providing adequate, resident centered care to the residents. Interview with DON on 2/14/24 at 2:44 PM revealed her expectation is that they need to care plan accurately and risk of not care planning may lead to not providing resident centered care. 2. Review of Resident #44's quarterly MDS assessment dated [DATE] reflected Resident #44 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses of hemiplegia on right side, cerebral infarction (stroke), apraxia (neurological disorder characterized by the inability to perform learned (familiar) movements on command), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) after stroke. Resident #44 had a BIMS of 0 and had unclear speech. Review of Resident #44's comprehensive care plan last updated 12/27/23 did not reflect Resident #44's communication deficit due to aphasia and apraxia. Observation on 02/13/24 at 10:04 AM with Resident # 44 revealed he had difficulty communicating and kept repeating and gesturing with hand I want to tell you something, then would try to talk but had difficult speaking it. When surveyor asked him if he wanted to use the Ipad he declined and continued to gesture and try to speak. Observation on 02/13/24 at 10:10 AM with Resident #44 communicating with Social Worker revealed he communicated with her using gestures and was able to answer yes/no questions. He would say yes, yes, yes if he agreed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 4 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 - Few Interview on 02/13/24 at 10:37 AM and 02/15/24 at 9:05 AM revealed Social Worker stated Resident #44 did communicate using gestures, singing it out and could point to items to express himself. Social Worker stated he used his IPAD to communicate when he wanted to. She thought Resident #44's communication deficit was care planned for Resident #44 . She stated Resident #44 did communicate more with people he was familiar and comfortable with. Social Worker stated Resident #44 had the communication deficit since admission. Interview on 02/14/24 at 10:56 AM with Resident #44's MPOA stated Resident #44 did have difficulty communicating due to history of stroke. Resident #44 stated he had been on therapy services in the past. Review of Resident #44's speech therapy evaluation dated 02/15/24 completed by Speech Therapist reflected Resident #44 had a history of CVA (cerebrovascular accident) and had aphasia. Clinical impressions reflected Resident #44 had severe-marked aphasia and expressive aphasia and apraxia; mild receptive aphasia and cognitive communication deficits. Pt has switched from a manual pictorial communication to preferring to use his Ipad, gestures and yes/no question responses to express his functional communication needs. Interview on 02/15/24 at 9:45 AM with Social Worker revealed Resident #44 did not have care plan for communication deficit so she reached out to MDS Coordinator to get it updated today. Interview on 02/15/24 at 11:18 AM with MDS Coordinator revealed Resident #44 should have been care planned for communication deficit. She stated she was responsible for care planning but she missed it when last reviewed quarterly. She stated Resident #44 had a stroke and would communicate by saying yes, yes yes to questions meant yes and if it is no would just say no. She stated Resident #44 used his Ipad, gestures and point at items if need to communicate to staff. She stated Resident #44 had been like this since she had worked at facility and had history of stroke. She stated the interventions and how Resident #44 communicated to staff was important to include in the resident's care plan. Review of facility's policy Care Plan, Comprehensive Person-Centered , revised 3/2022 revealed that . The comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional need is developed and implement for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 5 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 that a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 Residents (#26) reviewed for respiratory care, in that: Residents Affected - Few Resident #26 oxygen concentrator's humidifier bottle was not labeled or dated which was a facility policy requirement. These failures could place residents who received oxygen therapy at risk of respiratory infections. The findings were: Review of Resident #26's Quarterly MDS dated [DATE] reflected Resident #26 was an [AGE] year-old Male admitted in the facility on 8/3/2023. Relevant diagnoses include coronary artery disease (a condition that affects heart), Heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), Hypertension (high blood pressure), and Pneumonia (an infection that affects one or both legs). The Quarterly MDS reflected Resident #26 was on oxygen therapy. Review of Resident #26's comprehensive care plan dated 8/4/2023 reflected Resident #26 had Problem: Episodes of shortness of breath and is at risk for respiratory distress/ failure. Goal: Oxygen at 2 liters per minute via Nasal cannula. Intervention: Apply Oxygen per order, encourage to take slow deep breaths. Review of Resident #26's Physician order dated 1/24/2024 Oxygen at 2 Liters per minute via nasal cannula. Observation on 02/13/24 at 10:18 AM revealed that Resident #26's was on oxygen therapy via Nasal cannula and Oxygen concentrator's humidifier bottle was not labeled or dated. Interview with Resident #26 on 2/13/24 at 10:19 AM revealed that he had been on oxygen therapy for a while but could not tell the writer when the Oxygen tubing and humidifier bottle was changed. Interview with CNA A on 12/13/24 at 10:20 AM revealed that she was assigned to the resident and did not see the humidifier bottle empty. She stated that both the tubing and bottle should be dated and was done by Nursing and CNAs usually were not responsible for changing the tubing. Interview with LVN B on 12/13/24 at 10:26 AM revealed that Resident #26 was on continuous Oxygen therapy. She stated that Oxygen tubing and humidifier bottle was changed every Sunday by the night shift Nursing. She stated that both the oxygen tubing and humidifier bottle needs to be labeled and dated each time a new Oxygen delivery equipment was used. The risk of not dating or labeling the humidifier bottle was possible spread of infection. She also stated that she will immediately change the humidifier bottle with label it appropriately. Interview with the ADON on 2/14/24 at 2:30 PM revealed that her expectation was Nursing staff should be changing the tubing and humidifier bottle on a weekly basis , and the night shift was responsible for dating it. She also stated that if there was no label or date on either the humidifier bottle or oxygen tubing, the nursing staff will replace the tubing immediately and date it. She also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 6 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 revealed that the risk of not dating the oxygen equipment will cause lapses in infection control. Level of Harm - Minimal harm or potential for actual harm Interview with DON on 2/14/24 at 2:44 PM revealed that she was very new to the facility, but it was a standard nursing practice to date and change Oxygen humidifier bottles every Sunday and on an as needed basis. The risk for not changing or dating oxygen supplies can lead to infection lapses. Residents Affected - Few Facility's Oxygen storage policy updated 3/2019 revealed . Oxygen tubing, cannulas, nebulizers and face mask will be changed weekly and date/initialized when dispensed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 7 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 0880 Provide and implement an infection prevention and control program. 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 maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #12 and #18) of seven residents observed for infection control. Residents Affected - Some 1. CNA T failed to perform hand hygiene between glove changes, and when she went from dirty to clean during incontinence care for Resident #12. 2. The facility failed to ensure Resident #18's nasal cannula oxygen was not lying on wheelchair seat when not in use. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: 1. Record review of Resident #12's face sheet dated 02/15/2024 reflected she was [AGE] years old female. She was admitted to the facility on [DATE]. She was admitted with the diagnoses of Alzheimer's disease, osteoarthritis (is a degenerative joint disease that causes pain, stiffness, and loss of joint function in the hands, knees, hip, neck, and lower back), muscle weakness, depression, and insomnia. Review of Resident #12's Care Plan initiated 04/30/2021 reflected the resident was incontinent of bowel, and bladder. Resident#12 had an ADL (activity of daily living) self-care performance deficit related to mental, and physical conditions and the intervention was for the resident to be assisted by staff for incontinent care. In an observation 02/13/2024 at 10:39 AM. revealed CNA T entered Resident # 12's room and told the resident she was here to change the resident brief. CNA T unfasten Resident#12's brief, cleaned Resident#12's front area using one wipe per stroke, tacked the brief between Resident#12's legs. CNA T turned Resident#12 to her left side, cleaned the buttocks area using one wipe per stroke. CNA T pushed the brief underneath Resident#12, pulled the clean brief put it underneath the resident, removed the right-hand glove and put a clean one without hand hygiene. CNA T turned Resident#12 to her back, removed the dirty brief, and finished putting the clean brief on Resident#12, fastening it in the front. CNA T covered Resident#12 and adjusted her bed, with the same glove. CNA T removed glove and washed hands before exiting the room. Interview with CNA T on 02 /13/24 at 10:45 AM revealed she was supposed to perform hand hygiene after changing the dirty brief. She stated the dirty brief needed to be removed before putting the new one. She stated both gloves not just one was supposed to be changed with hand hygiene; before getting the clean brief; and she did not do it because the resident was on her side, and she was contracted. She stated she had training on hand hygiene , and that she supposed to wash hands for 20 seconds, and in between changing glove sanitized hands. She stated today just changed one hand glove by accident. Interview with ADON on 02 /15/24 at 09:41 AM she stated the process of incontinent care, explain the process to resident wash hands, gather supplies and put them close to the resident bed. Unfasten (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 8 of 9 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 675441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1400 Blackshill Dr Gainesville, TX 76240 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the brief, clean resident front to back using one wipe per stoke, turn resident to side, clean the buttocks area, the same way, back to front, using one wipe per stoke. Dispose of the dirty brief, change glove with hand hygiene. Put the clean brief on the resident. Cover, and make resident comfortable. Change glove with hands hygiene, dispose of trash, and lining appropriately. She stated expected the staff to do incontinent care the proper way, and the risk to residents was developing an infection. ADON stated the training on incontinent care was done, weekly, every week, she will pull certain staff and go over the training with them, she stated did not do all of them at the same time. Interview with the DON E on 02/15/2024 at 1:21 PM revealed he expected staff to wash their hands before care, when they went from dirty to clean, and after care was completed. DON E stated the dirty brief should be removed off, change glove with hands hygiene before proceeding to put on a clean one. DON E stated the staff were supposed to change both hands' glove at the same time. He stated the risk to residents' was developing an infection . Review of the facility's policy titled Hand washing revised February 2021, reflected, . hand washing is the single most important means of preventing the spread of infection. 2. Review of Resident #18's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body), cancer and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #18's comprehensive care plan last updated 12/01/23 reflected Resident #18 was unable to maintain oxygen saturation. Receives oxygen at 2-4 L/min. Observations on 02/13/24 at 10:07 AM revealed Resident # 18's nasal cannula oxygen tubing from portable oxygen cylinder was lying on resident's wheelchair seat. Observation on 02/13/24 at 10:10 am with LVN C revealed Resident #18's nasal cannula tubing from portable oxygen was lying on the resident's wheel chair seat. Interview on 02/13/24 at 10:11 AM with LVN C revealed Resident #18's nasal cannula oxygen tubing should be in a plastic bag and should not be lying on the wheelchair seat when not in use. She stated she will throw it away and replace it with a new one storing the new one in a plastic bag. Interview on 02/15/24 at 10:22 AM with DON N revealed she expected residents on oxygen not to have nasal cannula oxygen tubing on the wheelchair and should be bagged. She stated it was an infection control issue and risk for contamination for the nasal oxygen cannula to be lying on the wheelchair seat. Review of facility's policy Protocol for Oxygen Administration last updated March 2019 reflected under procedure, When not in use, oxygen cannuals and facemasks will be stored in plastic bags attached to oxygen concentrator or tank. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675441 If continuation sheet Page 9 of 9