Every finding on record at The Springs At Oldham Reserve

Based on observation, interview and review of facility policy the facility failed to provide infection control measures for one resident (Resident (R) 9) observed for enhanced barrier precautions; and one of two rooms observed for cleaning. In addition, the facility failed to monitor and assess the building's water system for Legionella and other opportunistic waterborne pathogens affecting the total census of 43.The findings include: Review of facility policy titled Infection Prevention and Control Program (IPCP) revised 11/15/2021, revealed the facility established and maintained an infection prevention and control program that provided a safe, and sanitary environment and also prevented the development and transmission of communicable diseases and infections. 1. Review of admission records in the facility medical record revealed the facility admitted Resident (R)9 with an indwelling urinary catheter on 11/29/2025. Admitting diagnoses included hypertension, congestive heart failure, diabetes, bacteremia, and paraplegia. Review of physician orders revealed an order for enhanced barrier precautions (EBP) dated 11/19/2025. Observation on 12/16/2025 at 10:00 AM, revealed R9 with an indwelling urinary catheter but no signage alerting staff of the EBP. Review of the facility's comprehensive care plan for R9 revealed R9 requires EBP during high-contact care related to presence of indwelling catheter, dated 12/03/2025. Review of the physician orders for R9 revealed an order dated 11/29/225 for staff to use EBP, wearing gown and gloves at minimum during high contact care activities. During an interview on 12/17/2025 at 9:45 AM with Licensed Practical Nurse (LPN) 8, she stated she did not know if R9 should be on EBP for the indwelling foley catheter. She looked in R9 Electronic Medical Record (EMR) and looked at the order, then stated she was unsure why R9 was not placed in EBP when the order was placed. She stated it is usually the responsibility of the nurse who acknowledges the order to place the signage and Personal Protective Equipment (PPE) outside the door. During an interview on 12/18/2025 at 9:48 with the Director of Nursing (DON), she stated she did not know why EBP were not initiated for R9. She stated it was her expectation for staff to be educated on proper PPE signage and to follow the guidelines to prevent the spread of diseases. During an interview on 12/18/2025 at 10:00 AM with the Administrator, he stated it was his expectation that staff followed facility policy for maintaining proper PPE for infection control. 2. Observation on 12/16/2025 at 3:14 PM revealed Housekeeper #1 exited room [ROOM NUMBER] wearing gloves and carrying a spray bottle. The housekeeper carried the spray bottle to the housekeeping cart and put the bottle in the cart. Housekeeper1 then picked up a mop and entered room [ROOM NUMBER] wearing the same gloves. The housekeeper set the mop down and left the room, without removing gloves or performing hand hygiene. Housekeeper1 went to the housekeeping cart and retrieved a cleaning cloth and a spray bottle and then returned to room [ROOM NUMBER] and cleaned the shower and finished mopping. The housekeeper then put the mop and cleaning supplies back into the housekeeping cart. She did not change gloves or perform hand hygiene and then pushed the cart down the hall wearing the same gloves. During interview with Housekeeper1 just after the observation, the housekeeper stated she should have changed her gloves, but she was in a hurry. On 12/16/2025 at 3:38 PM during interview with the Housekeeping Director, she stated staff were taught to change gloves and sanitize hands after cleaning each room. On 12/18/2025 at 10:07 AM during interview with the Administrator, he stated he expected housekeepers follow their infection control training and to change gloves and clean hands after cleaning a room. 3. Review of the facility policy Guidelines for Water Management policy, dated 08/30/2019 revealed, It is the policy of this facility to establish procedures to reduce risk of Legionella and other opportunistic pathogens. A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. On 12/16/2025 at 10:09 AM during interview with the Director of Plant Operations, he stated the facility did not have a risk assessment of the facility's water system. He further stated the facility tested yearly for legionella, and the most recent test was performed 02/10/2025, with no legionella was detected. On 12/17/2025 at 10:44 AM during interview with the Director of Plant Operations, he stated to prevent legionella the facility flushed the water in empty rooms, but he was not aware of how often they flushed the empty rooms in the facility as he did not keep a flow sheet. On 12/17/2025 at 4:44 PM during interview with the Facility Management Support Person (FMSP) he stated there was no risk assessment for bacteria or legionella for the facility's water system. The FMSP further stated the facility tested for Legionella once a year. The FMSP also stated the facility did not have a system to run water in rooms that were not in use.

Based on observation, interview, record review, and facility policy review, the facility failed to implement the comprehensive person-centered care plan for each resident for one of three residents sampled for enhanced barrier precautions (Resident (R) 9). R9 was care planned for enhanced barrier precautions but observations revealed no signage postedThe findings include:Review of facility policy titled Comprehensive Cre Plan Guideline, revised 05/22/2018, revealed the comprehensive care plan was created and implemented based on the resident needs and ensured appropriateness of services and communication that met the residents' needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines.Review of the facility's medical record Face Sheet revealed the facility admitted R9 on 11/29/2025 with diagnoses including hypertension, congestive heart failure, diabetes, bacteremia, and paraplegia.Review of the facility's Care plan for R9 revealed on 12/03/2025, the facility care planned R9 for EBP during high-contact care related to the presence of an indwelling catheter.Review of the facility's physician order for R9 revealed an order, dated 11/29/2025, indicating staff were to use EBP, including wearing gown and gloves at minimum during high contact care activities.Observation on 12/16/2025 at 10:00 AM, revealed no enhanced barrier precaution (EBP) signage for Resident (R) 9.During an interview on 12/17/2025 at 9:45 AM with Licensed Practical Nurse (LPN) 8, she stated she did not know if R9 should be on EBP for the indwelling foley catheter and was not aware that this was included on the resident's care plan. After reviewing the physician's order for EBP, LPN8 stated she was unsure why the facility did not place R9 in EBP when the order was placed. She stated it was usually the responsibility of the nurse who acknowledged the physician's order to place the EBP signage and personal protective equipment (PPE) outside the door. During an interview on 12/18/2025 at 9:48 AM with the Director of Nursing (DON), she stated it was her expectation for staff to follow care plans to ensure appropriate care was provided to the residents. During an interview on 12/18/2025 at 10:00 AM with the Administrator, he stated it was his expectation that staff followed the resident's care plans.

Based on observation, interview, and review of facility policy, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls when not attended for one of four medication carts.The findings include:Review of facility policy titled Medication Storage in the Facility revised 11/2018, revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Observation on 12/16/2025 at 10:00 AM revealed a medication cart on hall 400 was unlocked and unattended.During an interview on 12/16/2025 at 10:00 AM with Registered Nurse (RN)1, she stated she had just walked away from the cart and forgot to lock it. She stated it was important to keep it locked to keep people out of the medication cart, and to keep the residents safe.During an interview on 12/18/2025 at 9:48 AM with the Director of Nursing (DON), she stated it was her expectation that all medications carts were locked when not in use to prevent residents from getting into them and taking medications that did not belong to them.During an interview on 12/18/2025 at 10:00 AM with the Administrator, he stated it was his expectation that staff followed the medication storage policy to ensure safe storage for overall monitoring of medication and resident safety.