Kern Valley Healthcare District DP SNF

Based on interview and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) when Charge Nurse intentionally neglected to document, report, and assess Resident 1 after a fall incident. This failure had the potential for delay in care, Resident 1 feeling neglected, and injury.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 10/1/25, the MDS indicated Resident 1's BIMS (Brief Interview for Mental Status) score was 11 (a score of 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 had impairments to both upper extremities (shoulders, elbows, wrists, hands) and lower extremities (hips, knees, ankles, feet) of her body and Resident 1 was dependent (helper does all the effort) for chair/bed to chair transfers (the ability to transfer to and from bed to a chair or wheelchair).During a review of Resident 1's Behavior Note, (BN) dated 12/2/25 at 2:08 p.m. the BN indicated, Charge RN [Registered Nurse] found resident attempting to get out of bed to go play a game…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement a care plan for one of three sampled residents' (Resident 1) fall precaution. This failure had the potential to result injury for Resident 1.Findings:During a review of Resident 1's care plan (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on The Resident has had an actual fall, initiated 12/13/25. The care plan indicated one of the interventions was Fall mats to both sides of bed when resident is in bed.During a concurrent observation, interview, and record review, on 12/17/25 at 1:52 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room. Resident 1 was in her bed with one fall mat at bedside. Resident 1's care plan with the focus on The Resident has had an actual fall, initiated 12/13/25, was reviewed. LVN 1 confirmed Resident 1 was care planned to have fall mats on both sides of the bed. LVN 1 stated Resident 1 had one fall mat at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Neurological Evaluation [Neuro check- is a group of questions and tests to check for disorder of the spinal cord and brain], for one of three sampled residents (Resident 1) when Resident 1 had an unwitnessed fall. This failure had the potential for a delay in treatment and care for Resident 1, and had the potential for Resident 1 to suffer adverse health outcomes.Findings:During a review of Resident 1's Behavior Note, (BN) dated 12/2/25 at 3:11 p.m. the BN indicated, Resident [1] found on the floor sitting and naked and playing a game with my boys. RN [Registered Nurse] attempted to reorient resident to surroundings and she stated, I am going to eat your toes!. Resident was not aggressive or agitated but very confused and remains hallucinations of people and objects. Resident was dressed and place in Geri-Chair [a specialized, reclining, mobile chair on wheels designed for elderly or mobility-impaired] and Placed out by the nursing station to keep observing signed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct Medical Doctor (MD) and/or Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) resident assessments per the facility policy and procedure for seven out of seven residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7). This failure had the potential for residents' medical conditions to change without appropriate interventions by the MD or NP. Findings: During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 9/19/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 to 15 with the higher the score the more intact the cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) on Abuse Prevention Program - Reporting for two of three sampled residents (Resident 1 and Resident 2) when: 1. The facility did not report an allegation of sexual abuse to the California Department of Public Health (CDPH), the Ombudsman (representatives advocating residents in long-term care facilities) and the local law enforcement (LLE) within 24 hours. 2. The facility did not complete a follow-up investigative report (FIR) within five working days. These failures had the potential to result in continuous sexual abuse and emotional distress for Resident 1 and Resident 2. Findings: 1. During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 6/14/25, the SOC-341 indicated, (Activities Assistant [AA]) reported that (Resident 2) stated that (Resident 1) grabbed her breast. During a concurrent interview and record review on 6/26/25 at 1:39 p.m. with Director of Nursing (DON), the FAX Transmission Status (FTS), dated 6/16/25 was reviewed, the FTS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure on narcotic (pain medication) count, narcotic dispensing, and storage for one of three sampled residents (Resident 1). This failure resulted in missing narcotic medications and had the potential to affect Resident 1's pain control.During a review of the facility email (FEM), dated 6/24/25, the FEM indicated Resident 1's narcotic medications (morphine - a narcotic pain medication) were placed into the medication room on 6/11/25 but were not double locked in the narcotics drawer. Licensed Vocational Nurse (LVN) 1 accessed Resident 1's home medications during her evening shift (7 p.m. to 7:30 a.m.) to administer one morphine ER (extended release - medication that is released into the body over a period of time) 15 mg (milligram - a unit of measurement) pill to Resident 1. The FEM indicated, The (Resident 1's morphine) should not have been used, and the staff should have notified the provider (medical doctor) to see if an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure they staffed a Registered Nursed (RN) eight hours a day for seven days a week from 9/2024 to 12/2024. This failure had the potential to affect the quality of care of the residents and put the residents at risk for injury. Findings: During a review of the Payroll Staffing Data Report (PBJ) (an electronic system for facilities to submit staffing information) dated 10/1/24 to 12/31/24, the PBJ indicated, no RN hours dated 10/6,10/9,10/13,10/16,10/18,10/19,10/20,10/23/24,11/3,11/9,11/10,11/17,11/23, 11/24,11/28,11/29,11/30/24, 12/1,12/7,12/8,12/13,12/14,12/15,12/16,12/21,12/22, 12/24,12/25,12/26,12/27,12/28,12/29/24. During a concurrent interview and record review on 6/12/25 at 10:50 a.m. with Staffing Coordinator (SC) the facility's Staffing Log dated 9/2024 to 12/2024 was reviewed. The Staffing log indicated on the following dates there was no RN for the regulated eight hours per day: On 9/6/24, 6.28 RN hours worked. On 9/7/24, 0 RN hours worked. On 9/15/24, 3.68 RN hours worked. On 9/16/24, 0 RN hours worked. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label and store food in a sanitary manner when: 1. Food items were not closed and sealed appropriately in one of one dry storage room. 2. Food items did not have a received by date label in one of one dry storage room. These failures had the potential for Residents eating in the facility to be at risk of acquiring a foodborne illness. Findings: 1. During a concurrent observation and interview on 6/9/25 at 9:52 a.m. with [NAME] 1 in the kitchen's dry storage room, one bag of powdered Cocoa was on the shelf. The bag of Cocoa was not closed or sealed properly, it was open and exposed to room air. [NAME] 1 stated the bag should have been closed and sealed when it was opened. 2. During a concurrent observation and interview on 6/9/25 at 9:57 a.m. with [NAME] 1 in the kitchen's dry storage room, five bottles of [NAME] Brand Chocolate syrup were on the shelf of the dry storage room. All five bottles did not have a received by date. [NAME] 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility failed to ensure tab alarm orders and informed consents were obtained for two of nine Residents (Resident 45 and Resident 14). 1. Resident 45 had no order and no informed consent for tab alarm. 2. Reisdent 14 had no informed consent for tab alarm. This failure had the potential for staff to be untrained in the proper use of alarms. Findings: During an observation on 06/10/25 at 11:57 a.m. in Resident 45's room, Resident 45 had a tab alarm (safety monitor to prevent falls or wandering) attached from the back of the wheelchair to the back of Resident 45's T-shirt. During a review of Resident 45's Minimum Data Set (MDS-a standardized assessment tool to evaluate residents' health status and functional abilities), dated 3/19/25, the MDS indicated, Restraints and Alarms Resident chair alarm not used. During a concurrent interview and record review on 06/11/25 at 10:56 a.m. with Assistant Director of Nursing (ADON), Resident 45's Orders [undated], were reviewed. The orders indicated there was no order for a tab alarm. ADON stated there is no order for a tab alarm for Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to document changes and monitor for one of two residents (Resident 22 and Resident 7) when: 1. A resident (Resident 22) had an unwitnessed fall. This failure resulted in Resident 22's fall being undocumented. 2. A resident (Resident 7) had a medical condition not monitored. This failure had the potential for Resident 7 to not have his blood sugars monitored. Findings: 1. During a review of Resident 22's admission Record (AR) dated 11/28/23, the AR indicated, Alzheimer's disease (memory loss), fracture of left femur (broken bone), seizures (uncontrolled movements of the body), idiopathic normal pressure hydrocephalus (a condition affecting walking, cognitive, and bladder), impaired normal pressure hydrocephalus, macular degeneration (blurred or no vision), and difficulty in walking. During review of Resident 22's Brief Interview for Mental Status (BIMS), (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident. A score of 13 to 15 cognitively intact, 8-12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure dental needs were met, and followed up for one of two sampled residents (Resident 47). This failure resulted in Resident 47 not recieving dentures, feeling embarrassed, and refusing to socialize with other residents. Findings: During a review of Resident 47's admission Record (AR), the AR indicated, admission date 11/7/24. Diagnosis Information: depression [is a mood disorder that causes a constant feeling of sadness and loss of interest in daily activities]. During a review of Resident 47's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident. Scores range from 0 to 15, with higher scores indicating better cognitive function. A score of 13-15 suggests intact cognition, 8-12 suggests moderate impairment, and 0-7 suggests severe impairment.), dated 3/19/25, the BIMS indicated Resident 47's score is 14. During a concurrent observation and interview on 6/09/25 at 10:08 a.m. with Resident 47, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) grievance were investigated and resolved. This failure had the potential for psychosocial distress for Resident 1. Findings: During a review of Resident 1's Concern/Comment From, (CCF) dated 4/1/25, the CCF indicated, Today, I had a particularly upsetting interaction with (Activities Supervisor [AS]) While I was stretching my leg during the activity, (AS) told me (Resident 1), If you don't want to be here, you can just go.the comment made (Resident 1) feel unwelcome and as if (Resident 1) didn't belong. when (residents) play Yahtzee [dice game], (AS) takes it upon herself to roll the dice for us, preventing us from fully participating in the game. (AS) confronted (Resident 1) and said, Why do you always play with (activities assistant) and not me? I'm the one who bought you biscuits and gravy. (Resident 1) never asked (AS) to buy (Resident 1) anything, and this comment made (Resident 1) feel uncomfortable and awkward. During a concurrent interview and record review, on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to promote two of three sampled residents (Resident 1 and Resident 2) physical and emotional well-being. This failure resulted in Resident 1 and Resident 2 not to be able to fully take part in activities physically and the freedom to make their own choices. Findings: During a review of Resident 1's Minimum Data Set, (MDS – an assessment tool) dated 1/28/25, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). The MDS indicated Resident 1 had no impairment (loss of use) to upper extremities (shoulders, elbows, wrists, and hands). During an interview on 4/7/25 at 10:52 a.m. with Resident 1, Resident 1 stated the Activities Supervisor (AS) does not allow him to roll the dice in Yahtzee, he stated AS does not allow anyone to roll the dice. Resident 1 stated AS treats the resident like they are handicap. Resident 1 stated he chooses not to go to activities when AS is doing activities. During a review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide sufficient Certified Nursing Assistants (CNA) and Restorative Nursing Assistant's (RNA) to meet the needs for 20 of 31 sampled residents (Resident 3, Resident 4, Resident 5, Resident 6, Resident 8, Resident 10, Resident 11, Resident 13, Resident 15, Resident 16, Resident 17, Resident 19, Resident 21, Resident 22, Resident 23, Resident 26, Resident 29, Resident 30, Resident 40, and Resident 42). This failure had the potential for a decline in residents Range of Motion (ROM) and mobility. Findings: During an interview on 4/22/24 at 2:19 p.m. with Resident 17, Resident 17 stated the CNAs are always short staffed and it takes 45 minutes to answer the call lights. Resident 17 stated it mostly happens at night, but it also happens during the day. Resident 17 stated she has not gotten her exercises for several days or maybe weeks. During a review of Resident 17's BIMS, dated 4/25/24 the BIMS indicated, Resident 17 had BIMS score of 15 [Intact cognitive response]. During a concurrent interview and record review on 4/22/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one refrigerator and one freezer were monitored for temperature control. This failure had the potential for foodborne illnesses to be spread to residents. Findings: During a concurrent observation and interview on 4/23/24 at 9:32 a.m. with Director of Nursing (DON) and Activities Director (AD) in the Day room, the Day room refrigerator nor freezer had a thermometer inside. There were drinks in the refrigerator and ice cream in the freezer. DON stated this is where food brought in from the outside would be stored. DON and AD confirmed there were no thermometers. During a concurrent interview and record review on 4/23/24 at 10:29 a.m. with Plant Operations Manager (POM), the SNF Activities Refrigerator [Day room] report ([NAME]), dated 4/23/24, was reviewed. The [NAME] indicated, There are no data to be displayed. POM stated the [NAME] indicated there was no data because the sensor had been installed that same day. POM stated food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 21) was referred for a Preadmission and Resident Review (PASRR-screening tool used to determine if placement in a nursing facility is appropriate for those with mental illness and makes recommendations for specialized services based on the Level II evaluation) after a change in psychological status. This failure resulted in Resident 21 not receiving recommendations for specialized services to best meet her needs. Findings: During a concurrent interview and record review on 4/24/24 at 10:45 a.m. with the Social Worker (MSW) Resident 21's PASRR, dated 11/26/19 and Psychiatric Mental Health Progress Note (PMHPN), dated 8/22/23 were reviewed. The PASRR indicated, Generalized Anxiety Disorder [feelings of worry or restlessness that can interfere with daily activities]. The PMHPN indicated, Schizophrenia [mental disorder that affects a person's ability to think feel and behave clearly]. MSW stated the PASRR does not include diagnosis of schizophrenia. MSW stated Resident 21 received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to communicate the weightbearing status to the interdisciplinary team (IDT-group of healthcare professionals from different fields working together) for one of one sampled resident (Resident 13). This failure resulted in a delay of rehabilitative and restorative care to prevent further physical decline. Findings: During a concurrent observation and interview on 4/22/24 at 10:07 a.m. in Resident 13's room, Resident 13 was in bed with a brace on her right leg. Resident 13 stated she wanted to have therapy, but had not received any since she broke her leg about six weeks ago. During an interview on 4/23/24 at 10:30 a.m. with Physical Therapist (PT), PT stated she discontinued Resident 13's RNA (Restorative Nursing Assistant - light stretching and range of motion) on 3/29/24 because she was unable to determine the weightbearing status. During an interview on 4/23/24 at 12:08 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 13 went to the orthopedic doctor on 3/18/24. No orders or follow up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide care for the Foley catheter (tube placed into the bladder to drain urine) to prevent infections and other complications for one of four sampled residents (Resident 33). This failure had the potential to result in infections and injury to the penis or bladder. Findings: During an observation on 4/24/24 at 7:23 a.m. outside Resident 33's room, Resident 33's Foley catheter tubing was on the floor under the wheelchair. Licensed Vocational Nurse (LVN) 1 stated Resident 33 is currently being treated for a urinary tract infection (UTI-bladder infection) and his catheter tubing should not be on floor because of the risk for infection or getting pulled out. During an interview on 4/24/24 at 11:22 a.m. with Infection Preventionist (IP), IP stated Resident 33's catheter tubing should not have been touching the floor. IP stated Resident 33 is already at a high risk for infection. During a review of the facility's policy and procedure (P&P) titled, Indwelling Foley Catheter Care, dated 11/6/13, the P&P indicated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to: 1. Change a physician order, and 2. Communicate the change in the dietary order to provide the dietary preferences for one of three sampled residents (Resident 33). This failure resulted in Resident 33's preferences to not be honored and had the potential to result in further weight loss. Findings: 1. During a concurrent interview and observation on 4/22/24 at 12:44 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 33's room, Resident 33's meal tray contained a glass of milk that had been thickened (for those with swallowing difficulty) and a carton of reduced fat milk that had not been thickened. CNA 1 stated Resident 33 was served thickened milk by the kitchen, but Licensed Vocational Nurse (LVN) 3 told her Resident 33 was supposed to have gotten thin liquids. CNA 1 stated she went to the kitchen and got the carton of reduced fat milk. CNA 1 stated Resident 33's tray ticket indicated Resident 33's preference was for whole milk. CNA 1 stated she did not honor Resident 33's preference. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store oxygen tubing per policy for two of four sampled residents (Resident 13 and Resident 31). This failure had the potential to result in respiratory infections. Findings: During a concurrent observation and interview on 4/22/24 at 11:30 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 13's room, Resident 13's oxygen tubing was laying on the handrail of the bed. CNA 1 stated it is supposed to go in the plastic bag. During a concurrent observation and interview on 4/22/24 at 2:56 p.m. with Registered Nurse (RN) 1 in Resident 31's room, Resident 31's oxygen tubing was on the handrail of the bed. RN 1 stated if the tubing is not in use, it should have been placed in the plastic bag to avoid contamination. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy Supplies, dated 12/1/10, the P&P indicated, Purpose: To ensure residents receiving oxygen therapy. have clean equipment to decrease the risk of infection. All tubing will be placed in a plastic bag.