Every finding on record at All Saint's Maubert

Based on interview and record review, the facility failed to have a Director of Nursing for more than 5 months.This failure placed all residents at risk of substandard nursing care due to absence of leadership, oversight and accountability.During an interview on 8/18/25, at 10:08 a.m., with a different Facilty's Director of Nursing (FDON), FDON stated they were not the designated director of nursing and had assisted in collaboration with the Assistant Director of Nursing (ADON) with duties which needed a registered nurse.During a concurrent interview and record review on 8/19/25, at 10:01 a.m., with Human Resources, FDON's acceptance letter to another facility, untitled, dated 4/4/25, was reviewed. HR stated the letter indicated FDON was hired as the Director of Nursing at another facility. HR stated FDON was hired full time at another facility. HR stated there was no plan to hire a Director of Nursing for the facility and to have the ADON assigned as the Director of Nursing.During an internet search of the facility careers page performed on 8/19/25, at 10:30 a.m., the search indicated the facility did not have a job posting for a Director of Nursing.During an interview on 8/19/25, at 11:40 a.m., with Administrator (ADM), the ADM stated the facility did not have a Director of Nursing. The ADM stated they had been attempting to hire a Director of Nursing but was unable to find a suitable candidate.During an interview on 8/22/25, at 11:25 a.m., with the FDON, the FDON stated they did not have oversight or responsibility over the licensed nurses at the facility. FDON stated they were hired as the full-time Director of Nursing at a different facility.During a review of a facility document handwritten by the ADM, untitled, undated, the document was a list of Director of Nursing coverage from the 9/3/23 to 8/22/25. The document indicated the facility did not have a Director of Nursing starting from 3/15/2025.

Based on observation, interview, and record review, the facility failed to ensure, for Residents 1, 5, 6, 7, 8 and 9, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion. In addition, these failures resulted in the potential for avoidable medication errors. Findings: During an interview, on 8/18/25 at 9:50 a.m., the Medical Record Director (MRD) was requested to describe the scheduled medication accountability process. MRD's description included pharmacy Shipping Manifest were kept for 3-5 years and scheduled drug records were kept for 7-10 years. MRD stated the above records were kept onsite. MRD was asked to provide the pharmacy Shipping Manifests from 9/1/2022 - 12/31/22. During an interview, on 8/18/25 at 10:10 a.m., the Director of Nursing (DON) was requested to describe the scheduled medication accountability process. DON's description included the pharmacy delivered scheduled medication with a Shipping Manifest and a CDR. The receiving nurse confirmed the prescription details and signed the manifest. The manifest was filed in medical records. The prescription was placed in the medication cart, and the CDR was filed in the cart's binder. She stated that when a scheduled medication was discontinued, and there were doses remaining, the medication and CDR was given to the DON. DON and pharmacist destroyed the medication. DON and the pharmacist documented the destruction. During a concurrent interview and record review, on 8/18/25 at 12:35 p.m., the MRD identified pharmacy Shipping Manifests for:4414890 Resident 1 9/21/22 Oxycodone (narcotic pain reliever) 5 mg (milligram) tablet4387797 Resident 2 9/11/22 Oxycodone 10 mg tablet 4669598 Resident 3 10/31/22 Hydromorphone (narcotic pain reliever) 4 mg tablet4673297 Resident 4 11/1/22 Oxycodone/APAP (acetaminophen, pain reliever) 10/325 mg tablet4701179 Resident 5 11/7/22 Oxycodone/APAP 10/325 mg tablet4774410 Resident 6 11/26/22 Hydrocodone/APAP 5/325 mg tablet4759345 Resident 7 12/3/22 Oxycodone 5 mg tablet4817832 Resident 8 12/6/22 Oxycodone 5 mg tablet4908248 Resident 9 12/20/22 Oxycodone/APAP 5/325 tablet She was requested to provide the CDRs for identified prescriptions. During an observation, on 8/19/25 at 9:20 a.m., on Maubert South, medications were observed being administered using a medication cart.The medication cart was In front of room [ROOM NUMBER]. During a concurrent interview and record review, on 8/20/25 at 1:15 p.m., MRD identified pharmacy Delivery Manifests for 4701179 Resident 5 Oxycodone/APAP 10/325 #56, 4774410 Resident 6 Hydrocodone/APAP 5/325 #30, 4817832 Resident 8 Oxycodone 5 mg #45 and 4414890.02 Resident 1 Oxycodone 5 #22. MRD stated that the corresponding CDRs could not be located. During an interview, on 8/20/25 at 2:20 p.m., the DON was requested to provide the Consultant Pharmacist reports from 6/2022-6/2023. During a concurrent interview and record review on 8/21/25 at 11:15 a.m., DON identified Controlled Drug Record 4821618.01 for Resident 7.The DON was requested to compare the CDR for Oxycodone 5 mg tablet removed and the MAR. DON identified that the CDR documented doses were removed on 1/4/23 2315, 1/8/23 1700, and 1/9/23 1000. She stated there were no corresponding entries documented in the MAR. Continuing the interview, DON identified CDR 4876197 for Resident 9. The DON was requested to compare the CDR for Oxycodone/APAP 5/325 tablet removed and the MAR. DON identified that the CDR documented a dose was removed on 12/23/22. She stated there was no corresponding entry documented in Resident 9 MAR. Continuing the interview on 8/21/25 at 11:15 a.m., DON was aware the facility was unable to provide the CDRs for 4701179 Resident 5 Oxycodone/APAP tablet 10/325 #56, 4774410 Resident 6 Hydrocodone/APAP tablet 5/325 #30, 4817832 Resident 8 Oxycodone 5 mg tablet #45 and 4414890.02 Resident 1 Oxycodone 5 mg tablet #22. Continuing the interview, DON identified the Executive Quarterly Summary of Consultant Pharmacist's Medication Regimen Review (6/22-6/23). She reviewed the documents and stated there was no documentation of scheduled medication accountability problems. During an administrative record review, of the Facilities Policy and Procedure for Ordering and Receiving Controlled Medications showed, Procedures, 1. The director of nursing and the consultant pharmacist monitors for compliance with federal and state laws and regulations in the handling of controlled medications. 3. The pharmacy or the nursing care center prepares an individual resident-controlled substance record/receipt/log for each controlled substance medication prescribed for a resident. During an administrative record review, of Controlled Medication Storage showed, Procedures 1. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. 9. Current controlled medication accountability records are kept in MAR or narcotic book. When completed, accountability records are submitted to the director of nursing and maintained on file at the nursing care center. During an administrative record review, of the Facilities Executive Quarterly Summary of Consultant Pharmacist's Medication Regimen Review (6/22-6/23) did not show documentation of scheduled medication accountability problems.

Based on interviews and a review of facility records, the facility failed to ensure that a state licensed Nursing Home Administrator was overseeing facility operations when the unlicensed Operations Manager (OM) had assumed the role of administrator for more than 11 months.This failure resulted in residents, staff and facility operations being supervised and directed by unqualified administrative leadership for more than 11 months.During a record review of state nursing home administrator licensing database titled, Licensing and Certification License Verification Page, the database indicated OM did not have a Nursing Home Administrator license.During a review of state nursing home database titled, ELMS, the database indicated ADM 2 was the reported Administrator of the facility from 11/4/2020 to 3/13/2023. Administrator 3 (ADM 3) was listed as the Administrator from 3/14/2023 to 5/10/2024. OM was not listed as a former Administrator of the facility.During a record review of two facility financial self-report to the state agency both titled, Long Term Care Facility Integrated Disclosure and Medi-Cal Cost Report, one report dated 12/31/2021 and the second report dated 12/31/2022, the report dated 12/31/2021 indicated OM was reported as the facility Administrator from 12/15/21-12/31/2021 and ADM 2 was the facility Administrator until 12/14/21. The report dated 12/31/2022 indicated OM was reported as the facility Administrator from 1/1/22 to 11/2/22, and ADM 3 started as the facility Administrator on 11/3/22.During a record review of facility grievance form titled, Concern Form (Front), dated 3/20/22, form indicated OM was the Administrator and Abuse Coordinator.During a record review of state abuse reporting form titled, State of California - Health and Human Services Agency Report of Suspected Dependent Adult/Elder Abuse, dated 3/22/22, the report indicated the facility the abuse of a resident which occurred on 3/20/22. The report indicated OM was listed as the Administrator of the facility.During a record review of a facility contract titled [Contractor] Inpatient Services Agreement, dated 9/22/22, the contract indicated OM had signed the contract on 9/22/22 as the Administrator.During a concurrent interview and record review on 7/3/26, at 11:00 a.m., with the current Director of Nursing (DON 2), a facility document titled, [Facility], dated 7/3/26, was reviewed. DON 2 stated OM was the facility's Administrator from [DATE] - [DATE].During a review of state health and safety code titled, California Code, Health and Safety Code 1416.6, the code indicated it shall be a misdemeanor for any person to act or serve in the capacity of a nursing home administrator, unless he or she is the holder of an active nursing home administrator's license.A person who is acting as an administrator shall notify the program in writing within five days of acting in this capacity and provide factual information and specific circumstances necessitating the use of an acting administrator.No person shall act as an administrator for more than 10 days unless arrangements have been made for part-time supervision of his or her activities by a nursing home administrator who holds a license or provisional license under this chapter. Supervision shall include at least 8 hours per week of direct onsite supervision by the licensed administrator. The program shall be notified in writing of the nature of this arrangement. No person shall act as an administrator for more than two months without the written approval of the program.During a review of state regulation titled, Title 22, Chapter 3. Skilled Nursing Facilities, 72007 Administrator, the regulation defined an administrator as a person licensed as a nursing home administrator by the California Board of Examiners of Nursing Home Administrators.

Based on interview and record review, the facility failed to have a director of nursing for more than 5 months.This failure placed all residents at risk of substandard nursing care due to absence of leadership, oversight and accountability.During an interview on 8/18/25, at 10:08 a.m., with a different Facility's Director of Nursing (FDON), FDON stated they were not the facility's designated director of nursing and had assisted in collaboration with the Assistant Director of Nursing (ADON) with duties which needed a registered nurse.During a concurrent interview and record review on 8/19/25, at 10:01 a.m., with Human Resources, FDON's acceptance letter to another facility, untitled, dated 4/4/25, was reviewed. HR stated the letter indicated FDON was hired as the director of nursing at another facility. HR stated FDON was hired full time at another facility. HR stated there was no plan to hire a director of nursing for the facility and to have the ADON assigned as the director of nursing.During an internet search of the facility careers page performed on 8/19/25, at 10:30 a.m., the search indicated the facility did not have a job posting for a director of nursingDuring an interview on 8/19/25, at 11:40 a.m., with Administrator (ADM), the ADM stated the facility did not have a director of nursing. The ADM stated they had been attempting to hire a director of nursing but was unable to find a suitable candidate.During an interview on 8/22/25, at 11:25 a.m., with the FDON, the FDON stated they did not have oversight or responsibility over the licensed nurses at the facility. FDON stated they were hired as the full time director of nursing at a different facility.During a review of a facility document handwritten by the ADM, untitled, undated, the document was a list of director of nursing coverage from the 9/3/23 to 8/22/25. The document indicated the facility did not have a director of nursing starting from 3/15/2025.

Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when food items were stored less than six inches above the floor. These failures had the potential for contamination of food resulting in food borne illness for the 10 residents who lived at the facility.During an observation 8/18/25, at 3:09 p.m., central supply was observed with tube feeding formulas stored less than six inches above the floor. During an interview on 8/21/25, at 10:39 a.m., with Registered Dietician (RD), RD stated food stored less than six inches above the floor was a risk for contamination from pests, could have altered the food temperature and had the potential to cause resident sickness. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 2001, the P&P indicated, Food in designated dry storage areas are kept at least six (6) inches off the floor.

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for three sampled residents (Resident 2, Resident 15, Resident 16) when:Resident 2, 15, and 16's care plans did not address the use of psychotropic medications such as lorazepam (antianxiety) and sertraline (antidepressant), Modafinil (stimulant) for behavioral manifestations. Psychotropic medications are drugs used to treat mental illness.These deficient practices had the potential to result in the residents not receiving appropriate care, monitoring, and treatment.During a review of Resident 2's order summary dated 8/3/25, the order summary indicated the physician prescribed bupropion 100 mg Give 1 tablet via NG-Tube one time a day for depression manifested by (m/b) feeling sad; buspirone 10 mg Give 1 tablet via NG-Tube two times a day for anxiety m/b inability to relax; A review of Resident 2's order summary dated 8/12/25 indicated the physician prescribed lorazepam 1 mg Give 1 tablet via NG-Tube every 8 hours as needed for anxiety m/b restlessness, inability to relax.During a review of Resident 15's order summary dated 8/7/25, the order summary indicated the physician prescribed mirtazapine 7.5 mg Give 1 tablet via PEG-Tube at bedtime for depression m/b feelings of hopelessness; sertraline 50 mg Give 1 tablet via PEG-Tube for depression m/b persistent sadness in response to prognosis; lorazepam 0.5 mg Give 1 tablet via PEG-tube every 12 hours as needed for anxiety m/b inability to relax.During a review of Resident 16's order summary dated 8/16/25, the order summary indicated the physician prescribed modafinil (drug used to treat sleep disorders) 100 mg Give 1 tablet via PEG-tube one time a day for sleep cycle.During a review of Resident 2, 15, and 16's care plans and concurrent interview on 8/21/25 at around 12 p.m. the Assistant Director of Nursing (ADON) searched the electronic health records for the care plans to address the use of psychotropic medications and behavior manifestations for these residents. ADON stated they did not have care plans to address the residents' target behaviors, and she would update them now. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, undated, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure three residents (Resident 2, Resident 15, Resident 16) of three sampled residents were free of unnecessary drugs, when they were receiving psychotropic medications without being monitored for their target behaviors.These failures had the potential for residents to receive unnecessary medications and suffer adverse medication side effects.Definitions:Lorazepam - an anti-anxiety medication to reduce tension or anxiety. Its adverse consequences include increased risk of confusion sedation, and fallsBupropion is an antidepressant medication for depression. Its adverse consequences include agitation or anxiety, trouble sleeping, and suicidal thoughtsBuspirone - an anti-anxiety medication for short-term relief of anxiety symptoms. Its adverse consequences include nervousness or restlessness, and trouble sleeping or nightmares.Modafinil - is a stimulant drug that promotes alertness, wakefulness, and cognitive function. Its adverse consequences include anxiety and nervousness, confusion, depression, and suicidal thoughts.NG (Naso gastric) tube - a thin, flexible tube inserted through the nose and into the stomach. It is used for various medical purposes such as feeding.PEG (percutaneous endoscopic gastrotomy) tube - a feeding tube placed directly into the stomach through the abdominal wall.1.During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted on [DATE] and her diagnoses included anxiety disorder and post-traumatic stress disorder, and depression.During a review of the physician orders dated 8/12/25, the physician orders indicated Resident 2 was prescribed Lorazepam 1 mg one tablet every 8 hours as needed for anxiety m/b restlessness, inability to relax A review of the Medication Administration Record (MAR) for August 2025 indicated Resident 2 was administered Lorazepam one tablet via NG-Tube for anxiety. Further review indicated there was no monitoring of the target behavior.During a review of the physician orders dated 8/3/25, the physician order indicated Resident 2 was prescribed Bupropion 100 mg one tablet via NG-Tube one time a day for depression manifested by feeling sad.A review of the Medication Administration Record (MAR) for August 2025 indicated Resident 2 was administered Bupropion one tablet via NG-Tube for depression. Further review indicated there was no monitoring of the target behavior.During a review of the physician orders dated 8/3/25, the physician orders indicated Resident 2 was prescribed Buspirone 10 mg one tablet via NG- tube two times a day for anxiety manifested by inability to relax A review of the Medication Administration Record (MAR) for August 2025 indicated Resident 2 was being administered Buspirone one tablet via NG-Tube anxiety manifested by inability to relax. Further review indicated there was no monitoring of the target behaviorDuring a concurrent interview and record review on 8//21/25 at 10:45 a.m. with Assistant Director of Nursing (ADON), the Medication Regimen Review (MRR) dated 7/25/25, indicated behavior monitoring and side effect monitoring was recommended by the consultant pharmacist. Resident 2's physician orders and MAR and the care plans were reviewed, ADON stated they have orders for side effects monitoring for Resident 2 and they were monitoring that, but they did not add the orders for behavior monitoring and behaviors were not being monitored and documented. She stated they missed it. ADON stated Resident 2 was still getting the Lorazepam and it would end on 8/27/25. She stated monitoring was important just to make sure Resident 15 was still not experiencing that behavior. 2. During a review of Resident 15's admission record, the admission record indicated Resident 15 was admitted on [DATE] and originally admitted on [DATE] and her diagnoses included mental disorder, not otherwise specified.During a review of the physician orders dated 8/7/25, the physician orders indicated Resident 15 was prescribed Lorazepam 0.5 mg one tablet via PEG- tube every 12 hours as needed for anxiety m/b inability to relax. A review of the MAR for August 2025 indicated Resident 15 was administered Lorazepam one tablet via PEG-Tube for anxiety. Further review indicated there was no monitoring of the target behavior.During a concurrent interview and record review on 8//21/25 at 10:57 a.m. ADON, the Medication Regimen Review (MRR) dated 8/1/25 and 8/13/25 indicated behavior monitoring and side effect monitoring was recommended by the consultant pharmacist. Resident 15's physician orders and MAR and the care plans were reviewed, ADON stated they have orders for side effects monitoring for Resident 15 and they were monitoring that, but they did not add the orders for behavior monitoring and target behaviors were not being monitored and documented. She stated they missed it. ADON stated Resident was getting the PRN Lorazepam as she still needed it. ADON stated monitoring behavior was important to make sure Resident 15 was not feeling anxious and then they would stop the medication or if they got worse they would be increasing the medication. ADON stated the first order for the Lorazepam for Resident 15 was supposed to end today, but there was a new order pending the medical doctor (MD)'s signature. 3. During a review of the physician orders dated 8/16/25, the physician orders indicated Resident 16 was prescribed Modafinil 100mg one tablet via PEG- tube one time a day for sleep cycle.A review of the MAR for August 2025 indicated Resident 16 was being administered Modafinil one tablet via PEG-Tube for sleep cycle. Further review indicated there was no monitoring of the target behavior.During a concurrent interview and record review on 8//21/25 at 11:59 a.m. with ADON, the Medication Regimen Review (MRR) dated 7/25/25 indicated behavior monitoring and side effect monitoring was recommended by the consultant pharmacist. Resident 16's physician orders and MAR and the care plans were reviewed, ADON stated they have orders for side effects monitoring for Resident 16 and they were monitoring that, but they did not add the orders for behavior monitoring and behaviors were not being monitored and documented. ADON stated the medication was for sleep cycle for Resident 16. She stated monitoring behavior was important to see if the medication was effective, and if Resident was restless during the day or the opposite, not sleeping, keeping awake. ADON confirmed there was no behavior monitoring for the three residents in their physician orders and MARs. ADON stated there were also no care plans for the target behaviors for Residents 2, 15, and 16 and she would update them now. During an interview on 8/22/25 at 2:26 p.m. with ADON, ADON stated it was important to monitor to see if the residents were still manifesting those behaviors, as they might not need the medication anymore and then they might take them off.During a review of the facility's policy and procedure (P&P) titled Behavioral Assessment, Intervention, and Monitoring, undated, the P&P indicated, .The facility complies with regulatory requirements related to the use of psychotropic medications.The nursing staff identify, document, and inform the physician about specific details regarding changes in an individual's.behavior.including.behavioral symptoms.Circumstances that warrant a behavioral assessment of a resident include: a resident admitted to the facility on psychotropic medication that was started without a clear, documented indication.;new or worsening change in status or condition; an irregularity identified in the medication regiment review.monitoring of efficacy.plans (if applicable) for gradual dose reduction.The IDT monitors for and documents any new, worsening, or improved symptoms in the resident's behavior.interventions are adjusted based on the impact on behavior and other symptoms.

Based on observation, interview and record review, the facility failed to ensure the medication error rate of less than five percent when four errors were observed in 33 medication pass opportunities for four out of five sampled residents (Resident 9, Resident 10, Resident 17) resulting in 12.12% medication error rate.The errors were: Three residents were not identified using the required minimum of two resident identifiers prior to administering medications to each of them. For Resident 9, no physician or pharmacy clarification was done for a medication, fludrocortisone acetate tablet (a medication that increases blood volume and blood pressure) that had a Hold parameter on the bubble pack and had no parameters on the physician order for Resident 9.These failures had the potential to compromise patient safety and medication accuracy which could result in adverse effects to the residents. During a med pass observation on 8/19/25, between 8:15 a.m. and 10:24 a.m., Licensed Vocational Nurse (LVN) 1 did not utilize the required minimum of two resident identifiers when administering medications to three residents (Resident 10, Resident 16, Resident 17). During an interview on 8/19/25 at 4:27 p.m., with LVN 1, LVN 1 acknowledged that she did not verify the identity of the residents. She stated she knows the residents, but she needed to check their ID (identification) band and photo.During an interview with LVN 1 on 8/20/25 at 3:10 p.m. LVN 1 stated verifying the identity of residents prior to administering medications is important as it is part of the five rights to make sure she gives medications to the right patient.During a review of the facility's policy and procedure (P&P), titled Administering Medications, dated April 2019, the P&P indicated, .The individual administering the medication verifies the resident's identity before giving the resident his/her medications. Methods of identifying the residents include checking identification band; checking photograph attached to medical record; and if necessary, verifying resident identification with other facility personnel.During an observation on 8/19/25 at around 9:48 a.m. LVN 1 prepared four medications that included Fludrocortisone 0.1mg tablet for Resident 9 and gave each medication (med) to him separately via his PEG tube. The label on the bubble pack for Fludrocortisone indicated, Fludrocortisone Acetate Oral Tablet 0.1 mg Give I tablet via PEG-Tube twice daily for blood pressure management - Hold for blood pressure (BP) less than 100 and Heart Rate (HR) less than 55.During Medication Reconciliation [the process of comparing a patient's medication pass observations with the medical doctor (MD)'s orders (given incorrectly/omitted? MD's specifications for use such as timing, hold parameters for BP etc., manufacturer's specifications regarding preparation/administration, and accepted professional standards of practice] on 8/19/25 at 4:53 p.m. record it in the computer, but she wrote it down on paper. She stated she did not hold fludrocortisone acetate per the direction on the bubble pack to hold for BP less than 100 and HR less than 55 as the doctor's orders did not give any parameters. When asked, LVN 1 stated fludrocortisone acetate was for BP management as indicated on the order, but not sure if it was specifically for hypotension or hypertension for Resident 9.A review of the order summary report for active medications for August 2025 indicated, Fludrocortisone Acetate oral tablet 0.1 mg Give 1 tablet via PEG tube two times a day for blood pressure management, order date 6/10/25.During a telephone interview and record review on 8/20/25 at 10:55 a.m. with PharMerica Pharmacist (PP), PP stated the medication typically is ordered for low blood pressure. PP stated fludrocortisone acetate for Resident 9 was ordered for BP management and she believed it was for low pressure, and the parameters to hold for BP less than 100 and HR less than 55 did not make sense. She stated the original order had parameters and she did not see any note clarification from the doctor, and it should have been clarified with the doctor.During an interview on 8/20/25 at 3:03 p.m. LVN 1 stated the physician order for fludrocortisone acetate for Resident 9 initially had the BP and HR parameters, but the MD removed the parameters. She stated however, the bubble pack still had parameters. LVN I stated she should have clarified with the MD and put a sticker on the bubble pack. She stated that the direction not matching the order might cause confusion for the nurses and they might hold the medication.During concurrent interview and record review on 8/21/25 at 12:13 p.m. with the Assistant Director of Nursing (ADON), ADON stated the fludrocortisone acetate was ordered for low blood pressure for Resident 9 and the nurse should have notified the pharmacy to update the label on the bubble pack. ADON further stated they have a sticker they should have placed on the bubble pack instructions to indicate no parameters on the current order. When asked, ADON stated the medications were held for about four days on different times in July 2025. At 12:40 p.m. when asked, ADON stated she could not find any care plan for fludrocortisone acetate in Resident 9's chart. She stated the care plan was important, to know if the medication was working for the patient and what their goals and interventions were. During a concurrent interview and record review on 8/22/25 at 2:20 p.m. with ADON, ADON stated the MAR for Resident 9's fludrocortisone acetate with days with chart codes of 4 (Vital signs outside of parameter) or 5 (Hold/See nurse notes) were days that the medication was held. A review of the MAR dated July 2025 indicated, 7/1/25 (9 a.m. and 8 p.m.), 7/2/25 (9 a.m. and 8 p.m.); 7/5/25 (8p.m), 7/6/25 (8pm), 7/7/25 (9.m.), 7/8/25 (9 a.m.). During a review of the facility's policy and procedure (P&P), titled Medication Administration General Guidelines, undated, the P&P indicated, .Prior to administration, the medication and dosage schedule on the resident's MAR (Medication Administration Record) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions,.Apply a direction change sticker to label if directions have changed from the current label.

Based on observation, interview, and record review, the facility failed to adequately monitor and document the necessity of a physical restraint for one out of one resident (Resident 16), when staff did not monitor and document their specific reason for the restraint as ordered by their doctor for four days. This failure had the potential to result in isolation, depression and the unnecessary restraint of Residents 16. During a review of Resident 16's admission Record, printed 8/20/25, the record indicated Resident 16 was admitted to the facility in August 2025 with a diagnosis of Tracheostomy Status (an incision in the windpipe made to relieve an obstruction to breathing). During an observation on 8/18/25, at12:35 p.m. Resident 16 was observed lying in bed with a soft wrist restraint (a medical device that limits a patient's arm movement by securing their wrist to the frame of the bed) on their left hand. During a concurrent interview and record review on 8/19/25, at 4:32 p.m., with Assistant Director of Nursing (ADON), Resident 16's Doctors' Orders, dated 8/16/25, Progress Notes, dated 8/16/25 to 8/19/25, and Medication Administration Record, dated 8/16/25 to 8/19/25 were reviewed. ADON stated Resident 16's reason for a left wrist restraint was their history of pulling out their tracheostomy tube (a tube inserted into a tracheostomy to help with breathing). A review of Resident 16's doctor's order, dated 8/16/25, indicated May apply soft wrist restraint on the left hand as clinically indicated to prevent the resident from pulling out medical tubes and devices ordered to ensure safety and to help achieve optimum health outcome. ADON stated Resident 16 did not have monitoring of pulling out medical tubes documented in their medication administration record or progress notes. During an interview on 8/21/25, at 1:51 p.m., with ADON, ADON stated ongoing monitoring of Resident 16 for pulling out their medical tube was important to make sure their restraint was necessary. ADON stated unnecessary restraints can lead to depression and isolation. During a review of Resident 16's Medication Administration Record, dated 8/16/25 through 8/19/25, the Record indicated, resident 16 had the left wrist restraint applied on 8/16/25 through 8/19/25. During a review of the facility's policy and procedure (P&P) titled, Use of Restraint, revised April 21, 2022, the P&P indicated, When the use of restraints is indicated. the ongoing re-evaluation for the need for restraints will be documented.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - mental health assessment tool) for one of one sampled resident (Resident 8) was completed and coded accurately.This failure placed Resident 8 at risk to not receiving care and services appropriate to his needs. During a review of Resident 8's admission Record undated, the admission record indicated Resident 8 was admitted on [DATE] and has diagnosis of paranoid schizophrenia, a severe mental disorder characterized by hallucinations (sensory experiences like hearing voices) and delusions (fixed false beliefs), particularly involve persecution or being threatened.During a concurrent interview and record review on 8/22/25 at 9:10 a.m. with Minimum Data Set (MDS) Resource (R) stated Resident 8's PASRR Level I screening result indicated Resident 8 had a positive PASRR I and required a PASRR II evaluation. His PASRR Level II letter from Department of Health Care Services (DHCS) indicated, . Unable to Complete Level II Evaluation for Serious Mental Illness (SMI). MDSR stated the PASRR II was not completed because Resident 8 was discharged from another facility and transferred here. She stated they needed to resubmit another one. During an interview on 8/22/25 at 9:10 a.m. with MDS Coordinator (MDSC), MDSC stated upon Resident's admission, the admission department and the business office coordinate the PASRR and were supposed to send it to her for the MDS assessment, but she did not get one for Resident 8. She stated she would follow up with the admission to see if they initiated one.During an interview and record review on 8/22/25 at around 2:42 p.m. with Assistant Director of Nursing (ADON), ADON stated Resident 8 came from another nursing facility and the PASRR II was not completed. She stated they needed to reschedule another one for Resident 8 here, but it was not done. ADON stated PASRR II screening was important as they needed to evaluate to see if Resident still needed to be medicated so that he would not experience any behavioral issues or to harm himself or others.During a review of the facility's policy and procedure (P&P) titled, PASRR (Pre-admission Screening & Resident Review), undated, the P&P indicated, to ensure each patient in the facility is screened for a mental disorder or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) received good grooming when Resident 6 had long thick nails and facial hair.The failure placed Resident 6 at risk for having skin irritations and infections, and compromising his physical health, and not preserving his dignity.During a review of Resident 6's undated admission record, the admission record indicated Resident 6 was readmitted on [DATE] and originally admitted on [DATE] with multiple diagnoses that included anoxic brain damage (condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), dependent on a respirator and tracheostomy (a surgically created hole in the windpipe that provides alternative airway for breathing.During a review of Resident 6's Minimum Data Set (MDS- an assessment tool to guide care) dated 8/8/25, the MDS for activities of daily living (ADL) indicated Resident 6 was dependent on staff (Helper does ALL the effort or required the assistance of two or more helpers) for hygiene. During an observation on 8/19/25 at 2:25 p.m. and concurrent interview with Certified Nursing Assistant (CNA) 1, CNA 1 confirmed Resident 6's toenails needed trimming. She stated she was new and her first time working with Resident 6.During an interview on 8/20/25 at 3:14 p.m. with Licensed Vocational Nurse (LVN) 1 stated the nurses cut the nails for non- diabetic residents, and diabetic residents are referred to the podiatrist. She stated the podiatrist would now come in to see Resident 6. LVN 1 stated nail care is important to prevent the resident from having fungus and self-inflicting germs or bacteria that might live in the nails.During an interview on 8/20/25 at 4:52 p.m. with LVN 1, LVN 1 stated Resident 6 was not diabetic. She stated she did not know Resident 6's toenails were long and how long they had been like that. During an observation on 8/21/25 at 3 p.m. there were no CNAs on the floor. Per the Respiratory Therapist Nurse (RTN), the CNAs were in the other building having an in-service.During a concurrent observation and interview on 8/21/25 at 3:10 p.m. with LVN 2, Resident 6 was lying in bed, open eyes and awake. Resident 6 with gray facial hair above his lips and below the nose, around the cheeks and chin, unshaven and appeared unkempt. LVN 2 confirmed Resident 6 needed shaving and did not look good. She stated the CNA was supposed to shave the patient. LVN 2 stated she had come into the room to take care of Resident 6 but had not noticed Resident 6's facial hair as she would have assigned it to the CNA. LVN 2 stated some residents like to have mustache. When asked if they had asked Resident 9's Responsible Party (RP) for Resident's preference, LVN 2 stated she would check. During an interview on 8/21/25 at 4:29 p.m. with Assistant Director of Nursing (ADON), ADON stated that it was not okay for Resident 6's nails to be long. Upon reviewing Resident 6's chart, ADON stated Resident 6 was not diabetic, but his toenails were mycotic and needed referral to the podiatrist. ADON also acknowledged the facial hair on Resident 6 and stated the expectation was for their CNAs to groom the patients.During a concurrent interview and record review on 8/22/25 at 9:33 a.m. with Social Services Director (SSD), SSD stated she sends referrals to the podiatrist within 24 - 48 hrs. when she is notified by nursing. SSD stated they might not have told her Resident 6 needed the podiatrist. She stated the podiatrist had just told her they wanted to see Resident 6 and he was not on the list before. SSD stated Resident 6 had just been added to the list on 8/19/25 and the podiatrist sent her an email on 8/20/25 with the list.During a review of the facility's policy and procedure titled, Assistance with Activities of Daily Living (ADLs) for Dependent Residents, undated, the P&P indicated, .Staff will provide ADL care for dependent residents as follows: Bathing & hygiene.Dressing & Grooming.A review of the facility's P&P titled, Grooming, undated, indicated, It is the policy of the facility to ensure that all residents receive assistance with personal hygiene and grooming in accordance with individual need and preferences.Residents will be maintained in a clean, comfortable, and dignified manner at all times.Daily Grooming Care.Beards/mustaches groomed per resident preference. Nails trimmed and cleaned regularly, considering medical needs.A review of the facility's P&P titled, Foot Care, dated October 2023, indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice.Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals.

Based on observation, interview, and record review, Facility 1 failed to follow infection control practices to prevent the spread of infection in the facility when the following were identified: 1. Facility 1 did not demonstrate infection prevention practices were implemented as evidenced by the line list (a table that contains key information about each case in an outbreak) that showed uninfected residents becoming infected. 2. Facility 1 did not notify California Department of Public Health (CDPH) about the infection outbreak. 3. Facility 1 failed to separate direct care staff (assists with tasks such as bathing, dressing, personal hygiene, and medication management) for non-infected residents and Resident 1 and Resident 2 who were infected with Klebsiella Pneumoniae Carbapenemase (KPC, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality). These failures resulted in Residents 1, 2, 3, 4, 5, and 6 becoming infected with CROs. These include: 1. Residents 1, 2, and 3 became infected with KPC. 2. Resident 6 became infected with Carbapenem-resistant Acinetobacter baumannii (CRAB, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality) with New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). 3. Residents 4 and 5 became infected with Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, a bacteria that can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases). 4. The cross-contamination resulted in Residents 1, 2, 3, 4, 5, and 6 becoming infected with Carbapenemase-Resistant Organisms (CRO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used as a last-line treatment for serious infections). An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of Facility 1 to follow infection control practices to prevent further spread of infection among all 11 residents in Facility 1. The Administrator (ADM) was verbally notified of the IJ situation on 3/13/25 at 7:45 p.m. During a visit to Facility 1 on 3/25/25, Facility 1 provided an acceptable plan of action and the IJ was removed at 2:50 p.m. Findings: 1. During an interview on 3/13/25 at 12:56 p.m. with Facility 2 ' s Infection Preventionist (IP), IP stated she was the only IP for Facility 1 and Facility 2 even though both facilities have separate licenses and the regulations say otherwise. During an interview on 3/13/25 at 1:16 p.m. with Administrator (ADM), ADM stated there was only one shared IP for both Facility 1 and Facility 2. ADM stated he was not aware of the regulation that each facility should have an IP. ADM also stated that he thought one IP was enough because Facility 1 and Facility 2 are owned by one organization. During an interview on 3/14/25 at 3:31 p.m. with Facility 2 ' s IP, IP was requested to provide an updated line list for Facility 1 and Facility 2 with laboratory test dates (date laboratory results were reported), the residents tested positive for CRO infections. During a follow up interview and record review on 3/14/25 at 3:45 p.m. with Facility 2 ' s IP, IP provided an updated line list with laboratory test dates for Facility 2 but did not provide the line list for Facility 1. IP was requested to provide Facility 1 ' s line list record with laboratory test dates. During a phone interview on 3/20/25 at 8:04 a.m. with Facility 2 ' s IP, IP was requested to provide another updated line list for Facility 1 and Facility 2 with the laboratory test dates included. During a review of an undated document, titled, CRO List sent via email by Medical Record Director (MRD) on 3/20/25 at 10:09 a.m., the CRO List only included Facility 2 ' s line list and did not include Facility 1 ' s updated line list. During a communication sent via email on 3/21/25 at 8:47 a.m. to MRD, MRD again was requested to provide an updated line list for Facility 1. During a review of the undated document, titled, Facility 1 Multi-Drug Resistant Organisms (MDROs, are bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria) Line List, the line list sent via email on 3/21/25 at 10:17 a.m. by MRD, the Facility 1 line list was still not updated and did not include the laboratory test dates. During a record review of the undated document, titled, Facility 1 MDRO Line List, the line list indicated Residents 1, 2, and 3 were infected with KPC, Resident 4 and Resident 5 were infected with CRPA infection, and Resident 6 was infected with NMD infection. There were no laboratory results provided for Residents 3, 5, and 6 to confirm the date infection was identified. 2. During an interview on 3/13/25 at 3:15 p.m. with Facility 2 ' s IP, IP stated Facility 1 had a recent CRO outbreak last February 2025 and CDPH was only notified on 3/12/25 that there were new cases of infection identified. IP stated she forgot to inform CDPH about the two new cases because she was already overwhelmed with the CRO outbreak. IP further stated she did not think that the two new cases of infection noted in February were reportable. IP stated she should have reported it to the CDPH because more than one case of communicable infection was considered an outbreak. During a review of Facility 1 ' s Policy & Procedure (P&P) titled, Outbreak of Communicable Diseases, dated 2001, the P&P indicated, An outbreak is defined as one of the following .a. One case of an infection that is highly communicable or has serious health implications . During a review of Facility 1 ' s undated P&P titled, Reporting Communicable Diseases, the P&P indicated, The infection preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state specific reportable diseases . 3. During an interview on 3/13/25 at 12:36 p.m. with Facility 2 ' s IP, IP stated Facility 1 ' s CRO outbreak started around January 2025 when direct care staff from Facility 2 were assigned to Facility 1 on the same day. IP stated that she identified the previous scheduling coordinator assigned staff to work in Facility 2 then work in Facility 1. IP stated she informed the previous scheduling coordinator that sharing staff between Facility 1 and Facility 2 was not allowed because Facility 2 had an outbreak and Facility 1 did not have an outbreak. IP stated despite her instructions, the previous scheduler continued to assign direct care staff to work double shifts in Facility 1 after working in Facility 2 during January 2025. IP stated sharing staff between Facility 1 and Facility 2 contributed to Facility 1 ' s CRO infection outbreak. During an interview on 3/14/25 at 3:09 p.m. with Director of Nursing (DON), DON stated floating staff between Facility 1 and Facility 2 is not highly recommended. DON stated staff would start in Facility 2 and then move to clean buildings, including Facility 1. DON stated it was acceptable for staff to work from dirty buildings to clean buildings if wearing personal protective equipment (PPE, any piece of clothing or equipment that ' s worn by the employees to minimize exposure to biological, chemical, or any physical hazards on work site.) During a review of Facility 1 ' s document titled, Nursing and CNA Staffing Sign-in Sheet - Facility 1, dated 3/13/25, the document indicated Certified Nurse Assistant (CNA) 3 worked in Facility 1 from 7:00 a.m. to 3:30 p.m. and was assigned to Resident 1 and Resident 2 who were infected with KPC. During a concurrent observation and interview on 3/13/25 at 2:46 p.m. with CNA 3 in Facility 1, CNA 3 was observed in Resident 1 and Resident 2 ' s room that had signage indicating contact precautions (an infection control measures used to prevent the spread of diseases that are transmitted through direct or indirect contact with an infected person or environment) posted on the door. CNA 3 stated Facility 1 scheduled her in the afternoon to work in Facility 2 after her morning shift in Facility 1. During a review of Facility 2 ' s document titled, Nursing and CNA Staffing Sign-in Sheet, dated 3/13/25, the documented indicated CNA 3 worked in Facility 2 for evening shift (3:00 p.m. to 11:30 p.m.) after working the morning shift (7:00 a.m. to 3:30 p.m.) in Facility 1. During a phone interview on 3/14/25 at 10:36 a.m. with Scheduling Coordinator (SC), SC stated CNA 3 should have stayed in Facility 1 when CNA 3 worked a double shift. SC stated there was too much going on and she did not have time to check the staffing schedules for Facility 1 and Facility 2 on 3/13/25. During a follow up interview on 3/14/25 at 11:57 a.m. with Facility 2 ' s IP, IP stated she informed SC multiple times CNAs should not be shared between Facility 1 and Facility 2. IP stated CNA 3 worked on 3/13/25 in Facility 1 in the morning and continued the evening shift in Facility 2 ' s unit that did not have an outbreak. IP stated CNA 3 who provided direct care to Resident 1 and Resident 2 who were on contact precautions for KPC was also assigned to residents who did not have the infection and were not on contact precautions in Facility 2. IP stated the Local Public Health Department (LPHD) recommended that if staff were to work a double shift, staff should have stayed in one building or should have been allowed to have a gap of 8 hours in between shifts. IP stated the 8-hour gap in between shifts would have been an opportunity for staff to go home, take a shower, and change clothing. IP stated sharing staff between Facility 1 and Facility 2 could have exposed the residents to transmission of different infections such as CRAB, CRPA, NDM, KPC, etc. During an interview on 3/14/25 at 3:08 p.m. with DON, DON stated the facility ' s staff should have provided care to residents who did not have an infection first before being assigned to infected residents. DON stated sharing staff between buildings had the risk of transmission of bacteria to other residents who did not have an infection. DON stated residents who were exposed to an infection could have had resistance to antibiotics that could have potentially led to sepsis or death. During a review of Facility 1' s P&P titled, Multi-Drug Resistant Organisms (MDROs), dated 2001, the P&P indicated, MDROs are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs .Resident admission and Room Placement .3. When transmission continues despite adherence to standard and contact precautions and cohorting residents, assign dedicated nursing and ancillary service staff to the care of MDRO residents only.

Based on interview and record review, Facility 1 failed to ensure that a designated Infection Preventionist (IP) that adequately assesses, develops, implements, monitors, and manages the facility's Infection Prevention Control Program (IPCP) was employed at the facility . This failure resulted in an increase of Carbapanemase-Resistant Organism (CPO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used a last-line treatments for serious infections) infections in the Facility 1. Furthermore, the cross-contamination resulted in transmission of the infections to non-infected residents. Cross reference to F880 Findings: During a review of the facility provided undated letter from the local health department (LPHD), the document indicated, The increase in cases in the Facility 2 and now in the Facility 1 has raised concerns about the current implementation of infection control measures place following recommendations given .the increase in CPOs calls for strategic discussion to better minimize transmission occurring withing and across these two buildings . During a review of Facility 1's undated document, titled, Facility 1 MDRO (Multi-Drug Resistant Organims) Line List (a table that contains key information about each case in an outbreak), the line list indicated three residents with Klebsiella Peumoniae Carbapenemase (KPC, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality), one resident with New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family) and two residents with Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, a bacteria that can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases). During a record review of Facility 1 ' s undated MDRO Line List, the line list indicated Residents 1, 2, and 3 were infected with KPC, Resident 4 and Resident 5 were infected with CRPA infection, and Resident 6 was infected with NMD infection. During a review of Resident 1 ' s admission Record (AR), printed on 3/14/25, the AR indicated Resident 1 was admitted in February 2025 with diagnoses including encephalopathy (a general condition of brain dysfunction), acute respiratory failure (ARS, results from inadequate gas exchange by the respiratory system), and tracheostomy (surgical procedure that creates an opening in the windpipe and inserts a tube to provide airway) status. During a review of Resident 1 ' s Laboratory Report dated 2/27/25, the laboratory report showed, KPC gene detected, indicating Resident 1 tested positive for KPC organism infection. During a review of Resident 2 ' s AR, printed on 3/14/25, the AR indicated Resident 2 was admitted in January 2025 with diagnoses to include encephalopathy, ARS, tracheostomy status, and dependence on ventilator (a machine that helps you breathe). During a review of Resident 2 ' s Laboratory Report dated 2/27/25, the laboratory report showed, KPC gene detected, indicating Resident 2 tested positive for KPC organism infection. During a review of Resident 3 ' s AR, printed on 3/14/25, the AR indicated Resident 3 was admitted in December 2024 with traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), tracheostomy status, and encephalopathy, and dependence on ventilator. During a review of Resident 4 ' s AR, printed on 2/12/25, the AR indicated Resident 4 was admitted in February 2025 with a diagnosis of spastic quadriplegic cerebral palsy (is a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness). During a review of Resident 5 ' s AR, printed on 3/14/25, the AR indicated Resident 5 was admitted in February 2025 with diagnoses to include acute and chronic respiratory failure (typically caused when the volume of air flowing in and out of the lungs is uneven with the flow of blood to the lungs), tracheostomy status, and dependence on ventilator. During a review of Resident 6 ' s AR, printed on 3/14/25, the AR indicated Resident 5 was admitted in January 2025 with diagnoses to include myotonic muscular dystrophy (is a common multi-system disorder that affects the skeletal muscles (the muscles that move the limbs and trunk) as well as smooth muscles (the muscles that control the digestive system) and cardiac muscles of the heart), tracheostomy status, and dependence on ventilator. During a review of Resident 6 ' s Laboratory Report dated 2/12/25, the laboratory report showed, NDM detected, indicating Resident 6 tested positive for NDM organism infection. During an interview on 3/13/25 at 12:36 p.m. with Facility 2's Infection Preventionist (IP), IP stated when she was hired, she had been assigned the IP role for both Facility 1 and Facility 2. IP stated Facility 1 and Facility 2 were two different entities and operating under two different licenses. IP stated Facility 1's CRO outbreak started around January 2025 when direct care staff from Facility 2 were assigned to Facility 1 on the same day. IP stated that she identified the previous scheduling coordinator assigned staff to work in Facility 2 then work in Facility 1. IP stated she informed the previous scheduling coordinator that sharing staff between Facility 1 and Facility 2 was not allowed because Facility 2 had an outbreak and Facility 1 did not have an outbreak. IP stated despite her instructions, the previous scheduler continued to assign direct care staff to work double shifts in Facility 1 after working in Facility 2 during January 2025. IP stated sharing staff between Facility 1 and Facility 2 contributed to Facility 1's CRO infection outbreak. During an interview on 3/13/25 at 12:56 p.m. with Facility 2's IP, IP stated she asked upper management why the IP role was being shared between Facility 1 and Facility 2. IP stated the CRO outbreak between the two facilities was overwhelming and required a lot of monitoring. IP stated she worked 45 hours average in a week as an IP between Facility 1 and Facility 2. IP stated having one designated IP role for each facility required at least 40 hours per week. IP stated a designated IP in each facility could have helped focus on infection control and could have helped contain the outbreak. IP further stated she was the only IP for Facility 1 and Facility 2 even though both facilities have separate licenses and the regulations say otherwise. During an interview on 3/13/25 at 1:16 p.m. with Administrator (ADM), ADM stated there was only 1 shared IP for both Facility 1 and Facility 2. ADM stated he was not aware of the regulation that each facility should have an IP. ADM also stated that he thought 1 IP was enough because Facility 1 and Facility 2 are owned by one organization. During a review of the facility ' s policy and procedure (P&P), titled, Infection Preventionist, dated September 2022, the P&P indicated, The IP is responsible for coordinating the implementation and updating the Infection Prevention Control Program .The IP is employed on site and at least part time .The IP is scheduled with enough time to properly assess, develop, implement, monitor, and manage the IPCP, address training requirements .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan (a document that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), for two of five sampled residents (Resident 1 and Resident 2), when Resident 1 and Resident 2 did not have a care plan to address their antibiotic-resistant infection, Klebsiella Pneumoniae Carbapenemase (KPC, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality). This failure had the potential for Resident 1 and Resident 2 to not receive person-centered appropriate care, monitoring, and treatment. Findings: During a review of Resident 1 ' s admission Record (AR), printed on 3/14/25, the AR indicated Resident 1 was admitted in February 2025 with diagnoses including encephalopathy (a general condition of brain dysfunction), acute respiratory failure (ARS, results from inadequate gas exchange by the respiratory system), and tracheostomy (a surgically created hole makes through your neck and into your windpipe. It bypasses your nose, mouth and throat to help a person breathe) status. During a review of Resident 1 ' s Laboratory Report, dated 2/27/25, the laboratory report showed, KPC gene detected, indicating Resident 1 tested positive for KPC organism infection. During a review of Resident 2 ' s AR, printed on 3/14/25, the AR indicated Resident 2 was admitted in January 2025 with diagnoses to include encephalopathy, ARS, tracheostomy status, and dependence on ventilator (a machine that helps you breathe). During a review of Resident 2 ' s Laboratory Report, dated 2/27/25, the laboratory report showed, KPC gene detected, indicating Resident 2 tested positive for KPC organism infection. During a review of Resident 1 and Resident 2 ' s Care Plan, Resident 1 and Resident 2 did not have comprehensive care plans to address the KPC infections. During an interview on 3/19/25 at 1:58 p.m. with Director of Nursing (DON), DON stated the facility should have developed the care plans for all residents who had infections especially during the outbreak (usually caused by an infection, transmitted through person-to-person contact, animal-to-person contact, or from the environment or other media) in the facility. DON stated he did not think about implementing and creating an individualized care plan for infected residents. DON stated they were only focused on the type of isolation each resident needed and not the specific infection each resident had. DON stated the facility should have had a person-centered or individualized care plan for all the residents who became infected. DON stated a comprehensive care plan should have been created to provide quality care because each resident had different medical conditions and situations. During a review of the facility ' s policy and procedure (P&P), titled, Care Plans – Comprehensive, revised in September 2010, indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, nursing mental, and psychological needs is developed for each resident .3. Each resident ' s comprehensive care plan is designed to .a. Incorporate identified problem areas .b. Incorporate risk factors associated with identified problems .8. Assessments of residents are ongoing, and care plans are revised as information about the resident ' s condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .a. where there has been a significant change in the resident ' s condition.

Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications when medications were stored in the Director of Nursing (DON) office that had the door completely open and without supervision. This failure had the potential to result in loss or diversion of medications. Findings: During an observation on 2/5/24 at 10:50 a.m., the DON's office was open and there was no staff inside the office. There were medication blister packs (card that packages doses of medication within small, clear, or light resistant, amber colored, plastic bubbles (or blisters) and normal saline bags inside a clear plastic bag sitting on the floor next to a safe. The DON's office was a few steps from the stairway leading to the building exit. During an observation and concurrent interview on 2/5/24 at 11:40 a.m. with Assistant Director of Nursing (ADON), ADON stated the medications were extra medications that were removed from the medication cart, waiting to be destroyed by the Licensed Nurse and the Consultant Pharmacist. ADON stated the medications should have been stored inside the locked medication room and not inside the DON's office. ADON also stated, inside the clear plastic bag were medication cards that included three blister packs of midodrine (used to increase blood pressure), two blister packs of hydralazine (used to lower blood pressure), baclofen (relaxes muscle), and two blister packs of cyclobenzaprine (muscle relaxant). During an interview on 2/5/24 at 11:58 a.m. with DON, DON stated the DON's office was usually left unlocked, so medications were not secure whereas the medication room was always locked and only the licensed nurses had access. During a review of the facility's policy and procedure (P&P) titled Disposal of Medications, Syringes and Needles Discontinued Medications, copyright date 2007, the P&P indicated Medications awaiting disposal or destruction are stored in a locked secure area designated for that purpose until destroyed or disposed of through an authorized destruction center or licensed reverse distributor as allowed by regulation.

Based on observation, interview and record review, the facility failed to develop and implement infection control and prevention policies and procedures as evidenced by the following: 1. The facility laundry room contained: Clean mop heads, unused cleaning cloths, and unused Restorative Nurses Aids (RNA) Slings (a vest used by staff when assisting residents with mobility), stored in the same area as items waiting to be laundered. Staff personal use items: sweater, shawl, and a cup of coffee were in the area designated for clean resident linens. 2. Laundry Aide (LA) mopped the clean and dirty laundry room areas with the same mop head, using a solution with unknown chemicals. 3. The Soiled Utility Room had liquid medical waste (used suction canisters) containers stored together with biohazardous sharps (used needles, scalpels, scissors, etc.) containers. 4. The facility's Infection Control Program did not include a water management program to prevent exposure to Legionella (a bacteria commonly found in water systems which can result in serious illness, including pneumonia and death). These failures placed residents, staff, and visitors of the facility at risk for development and transmission of communicable diseases and infections. Findings: 1. During a concurrent observation, and interview on 10/24/23 at 1:15 p.m., in the facility's Laundry Department, with the facility's LA, Maintenance/Housekeeping Director (MHD) and Infection Preventionist (IP), and an interpreter to translate for non-English speaking staff, in the area dedicated to dirty laundry, were multiple hampers with dirty clothing and linen, the area also had a bin which contained clean, laundered mop heads, cleaning cloths, and Restorative Nurses Aids (RNA) slings, with no demarcation to indicate separation of clean and dirty items. The area dedicated to clean laundry had a sweater, shawl on a chair, and a cup of coffee was on a shelf which also held clean, laundered linen. LA stated the sweater, shawl, and coffee cup in the clean laundry room belonged to her. During a review of the facility's P&P titled, Maintenance Policy & Procedure, dated 12/31/15, indicated, maintenance of a safe, and sanitary environment ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. Maintenance activities include providing a functional, sanitary, and comfortable environment. Ensuring that all equipment, buildings, spaces, and fixtures are kept in operable condition. 2. During an observation on 10/24/23 at 10 a.m., Laundry Assistant (LA) mopped the floor in the area for contaminated laundry (dirty floor). LA moved into the area for clean laundry and mopped the floor without changing the mop head or mopping solution. During a concurrent observation, and interview on 10/24/23 at 1:15 p.m., in the facility's Laundry Department, with the facility's LA, Maintenance/Housekeeping Director (MHD) and Infection Preventionist (IP), and an interpreter to translate for non-English speaking staff, LA stated she did not know what chemicals had been in the mop water solution she had used to mop the laundry room floor as she had not mixed the mopping solution. MHD and IP stated specific chemicals needed to be used to ensure floors were properly sanitized, so it was important to know what chemicals were in the mopping solution. 3. During a concurrent observation, and interview on 10/24/23, at 1:45 p.m., on 2-South, with MHD, IP, the Director of Nursing (DON), and Administrator (Admin), in the facility's Soiled Utility Room, a biohazardous waste red bin contained used suction cannisters and full Sharps containers. MHD was unable to provide a date when the vendor would remove the biohazardous waste bin. IP stated Sharps containers must be placed in separate bins from liquid biohazardous waste containers. IP stated the current red bin storage was improper and not in accordance with facility policy and procedure (P&P). During a concurrent interview and record review on 10/24/23, at 2:15 p.m., with the IP, DON, Respiratory Manager (RM), MD, RD, and Admin, the facility's Infection Control and Prevention Plan (IC/IP), undated, and the P&P titled, Medical Waste- Segregating and Separating, last revised May 2012, were reviewed. The Medical Waste- Segregating and Separating P&P indicated, medical waste from this facility will be segregated from general waste in accordance with current federal and state guidelines. Policy Interpretation and implementation: Designated individuals will be responsible for separating (to the extent practical) medical waste generated: a. sharps (needles, glass, scalpels, and syringes). b. Other regulated medical waste. c. other items per state specific regulation. 4. During a concurrent interview and record review on 10/25/23, at 11a.m., with the IP and MHD, the facility policy and procedure (PNP) titled, Legionella Water Management program, revised 2/2022, was reviewed. The MHD confirmed the facility had no process in place to monitor and test the facility's water system to ensure the water was free of Legionella. During a review of the facility policy and procedure (PNP) titled, Legionella Water Management program, revised 2/2022, the PNP indicated, The facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella.

Based on observation, interview, and record review the facility failed to take reasonable care for the protection of one (Resident 6) of eleven sampled residents' clothing from loss or theft. The facility failure to ensure residents clothing was labeled before laundering resulted in an inability to identify specific ownership of clothing and subsequent loss of clothing. Findings: During an interview on 10/23/23, at 11 a.m., in Resident 6's room, a family member (RP 6) stood next to Resident 6's bedside. RP 6 stated Resident 6 had multiple clothing items that had been laundered by the facility and never returned to Resident 6. During an observation on 10/24/23, at 1:15 p.m., in the facility's Laundry Department there was a bin containing unlabeled residents' heel protectors, clothing, and positional aids. During an interview on 10/24/23, at 1:20 p.m., with the Maintenance/Housekeeping Director (MHD) and the Laundry Aide (LA), the MHD stated the items in the laundry bin had been laundered but were unlabeled, so the original owners could not be identified and so the items could not be returned to the original owners. During a review of the facility's policy and procedure (P&P) titled, Personal Property, the P&P indicated, Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits unless doing so would infringe on the right or health and safety of other residents . The Resident's personal belongings and clothing are inventoried, labeled, and documented upon admission and updated as necessary. The belongings are stored in designated areas for safety and retrieval purposes.

Based on observation, interview, and record review, the facility failed to provide wound care consistent with professional standards of practice for one (Resident 66) of eleven sampled residents when: the nursing staff inaccurately documented wound status, nursing staff failed to perform hand hygiene before donning gloves before wound treatment, and a certified nursing assistant incorrectly cleaned a wound. These failures placed residents at risk for infection, for wounds to worsen, and new wounds to develop. See also tags F 656, F697, and F 726. Findings: During a review of Resident 66's Admission Record, undated, the Admission Record indicated the facility admitted Resident 66 on 10/9/23, with diagnoses which included but were not limited to chronic osteomyelitis (bone infection), and pressure ulcers (A pressure ulcer develops when one or more layers of skin and tissue are damaged from continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone.) on both heels and both buttocks (also named the ischial area after the underlying bones). The Admission Record indicated the pressure ulcers on the right and left buttock, and right and left heels were all Stage 4 pressure ulcers. During a review of Resident 66's Minimum Data Set (MDS, an assessment tool used to plan and direct resident care), dated 10/13/23, the MDS indicated Resident 66 spoke English; had intact mental abilities for attention, orientation, and ability to register and recall information; was able to voice his needs; and was totally dependent upon facility staff for all his care needs including mobility in and out of bed, and repositioning. During a review of Resident 66's facility assessment document titled, Braden Scale for Predicting Pressure Sore Risk, dated 10/9/23, the assessment document indicated Resident 66 was at Moderate Risk for developing pressure sores. During a review of the Physician's Orders for Resident 66, initiated 10/19/23, the orders instructed staff to cleanse bilateral ischial wounds with normal saline solution, pat dry, apply antibiotic ointment, lightly pack with dry gauze, and cover with a dry dressing. During a review of Resident 66's care plan titled, Impaired Skin Integrity, initiated 10/9/23, the care plan interventions included: administer treatments as ordered, monitor for effectiveness, check skin during daily care provisions, float heels using pressure relieving device for heels, report abnormal laboratory values to physician, for wound documentation record location, size (length, width, and depth), color, surrounding skin, presence/absence of drainage and signs of healing. During a concurrent observation and interview on 10/23/23, at 11:15 a.m., with Resident 66, Registered Nurse (RN) 1, and Certified Nursing Assistant (CNA) 1, in Resident 66's room, nursing staff prepared to provide wound care for Resident 66's buttocks pressure wounds. RN 1 and CNA 1 donned gloves, without performing hand hygiene prior to donning the gloves. CNA 1 removed the fecal bag (a plastic bag to collect feces) and used gauze to clean the anus and surrounding skin, then used the same gauze to wipe around the perimeter of the right buttock wound. RN 1 stated the buttock wound was a Stage III, because the wound was to the level of bone. RN 1 stated she was still learning how to assess pressure wounds. RN 1 measured the buttock wound, and stated the wound was seven centimeters by 1.5 centimeters. RN 1 stated the measurements did not include wound depth or any tunneling (areas of damage and tissue loss extending under the skin) of the wound. RN 1 performed wound care treatment for Resident 66's bilateral heel deep tissue injury wounds. RN 1 stated the heel wounds were a Stage I pressure ulcer because the skin was not broken. During a concurrent interview and record review on 10/24/23 at 11:04 a.m., with the Director of Nursing (DON), Resident 66's clinical record was reviewed (MDS, care plans, Physician's Orders, laboratory tests, Braden scale assessment, nutrition consult, Medication Administration Record, Treatment Administration Record, and nurse progress notes). The DON confirmed nurses should refer to the National Pressure Ulcer Advisory Panel (NPUAP) for staging, assessment and measuring. The DON stated according to NPUAP if wound has progressed down to the bone, it is a Stage IV not Stage III as RN1 stated. The DON also stated that Resident 66's heels are DTI and according to NPUAP that means they are at least a Stage II or IV. The DON stated CNA 1 should not have used the same gauze to cleanse the rectum and then wipe around the open wound with the same gauze. During an interview on 10/26/23, at 12:06 p.m., with Physician (PH) 1, PH 1 said he performed Resident 66's weekly wound assessments. PH 1 stated Resident 66 had bilateral Stage IV ischial wounds, and deep tissue injury wounds on both heels, which are considered Stage III or Stage IV. PH 1 stated Resident 66 should be assessed and medicated for pain as needed before dressing changes and wound care. PH 1 stated it was important nursing staff accurately assessed wounds during the six days between his visits, as there could be significant changes during the week, including worsening of the wounds. PH 1 stated a wound treatment nurse should be able to accurately document wound assessment, measurement and staging. PH 1 stated there was a certification course available for wound care nurses. PH 1 stated RNs should be utilizing NPUAP Guidelines as a resource and reference for wound assessment and staging. During a review of the facility's policy and procedure (P&P) titled, Pressure Injuries/Skin Breakdown- Clinical Protocol, last revised April 2018, indicated Assessment and Recognition: 1. The nursing staff should assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, weight loss, and history of pressure ulcers. 2. If a skin issue is noted the nurse should describe and document/report the following: anatomical location, stage, size, (length, width, and depth), sinus tracts, undermining, presence of exudates or drainage, necrotic tissue, (slough/eschar), granulation, and epithelial tissue, skin surrounding the wound; pain, resident's mobility status, current treatments, and active diagnoses that may impact skin. During a review of the Centers for Disease Control (CDC) article titled, Hand Hygiene Guidance, dated 1/30/20, the CDC article indicated, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient; before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or the patient's immediate environment; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal.

Based on observation, interview and record review, the facility failed to ensure nursing staff had sufficient skills and competencies to perform wound care treatments for one (Resident 66) of 11 sampled residents. The failure to ensure Registered Nurse 1 (RN 1) was able to accurately assess and document Resident 66's pressure wounds had the potential to result in development or worsening of Resident 66's pressure ulcers. (A pressure ulcer develops when one or more layers of skin and tissue are damaged from continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone.) See also tags F 656, F 686, and F 697. Findings: During a review of Resident 66's Admission Record, undated, the Admission Record indicated the facility admitted Resident 66 on 10/9/23, with diagnoses which included but were not limited to chronic osteomyelitis (bone infection), and pressure ulcers on both heels and both buttocks (also named the ischial area after the underlying bones). The Admission Record indicated the pressure ulcers on the right and left buttock, and right and left heels were all Stage 4 pressure ulcers. During a review of Resident 66's Minimum Data Set (MDS, an assessment tool used to plan and direct resident care), dated 10/13/23, the MDS indicated Resident 66 spoke English; had intact mental abilities for attention, orientation, and ability to register and recall information; was able to voice his needs; and was totally dependent upon facility staff for all his care needs including mobility in and out of bed, and repositioning. During a review of the Physician's Orders for Resident 66, initiated 10/19/23, the orders instructed staff to cleanse bilateral ischial (both buttocks) wounds with normal saline (dilute salt) solution, pat dry, apply antibiotic ointment, lightly pack with dry gauze, and cover with a dry dressing. During a concurrent observation and interview on 10/23/23, at 11:15 a.m., with Resident 66, Registered Nurse (RN) 1, and Certified Nursing Assistant (CNA) 1, in Resident 66's room, nursing staff provided wound care for Resident 66's buttocks pressure wounds. CNA 1 removed the fecal bag (a plastic bag to collect feces) and used gauze to clean the anus and surrounding skin, then used the same gauze to wipe around the perimeter of the right buttock wound. RN 1 stated the buttock wound was a Stage III, because the wound was to the level of bone. RN 1 stated she was still learning how to assess pressure wounds. RN 1 measured the buttock wound, and stated the wound was seven centimeters by 1.5 centimeters. RN 1 stated the measurements did not include wound depth or any tunneling (areas of damage and tissue loss extending under the skin) of the wound. RN 1 performed wound care treatment for Resident 66's bilateral heel deep tissue injury wounds. RN 1 stated the heel wounds were a Stage I pressure ulcer because the skin was not broken. During a concurrent interview and record review on 10/24/23 at 11:04 a.m., with the Director of Nursing (DON), Resident 66's clinical record was reviewed (MDS, care plans, Physician's Orders, laboratory tests, Braden scale assessment, nutrition consult, Medication Administration Record, Treatment Administration Record, and nurse progress notes). The DON confirmed nurses should refer to the National Pressure Ulcer Advisory Panel (NPUAP) for staging, assessment and measuring of pressure ulcers. The DON stated according to NPUAP if a wound has progressed down to the bone, it is a Stage IV wound. The DON stated Resident 66's heels were a deep tissue injury wound (injury from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss) and according to NPUAP were considered to be a Stage II to Stage IV wound. The DON stated CNA 1 should not have used the same gauze to cleanse the rectum and then clean around an open wound. The DON stated gloves should be changed after removing dirty dressings and before applying a clean dressing. During an interview on 10/26/23, at 12:06 p.m., with Physician (PH) 1, PH 1 said he performed Resident 66's weekly wound assessments. PH 1 stated Resident 66 had bilateral Stage IV ischial wounds, and deep tissue injury wounds on both heels, which are considered Stage III or Stage IV. PH 1 stated Resident 66 should be assessed and medicated for pain as needed before dressing changes and wound care. PH 1 stated it was important nursing staff accurately assessed wounds during the six days between his visits, as there could be significant changes during the week, including worsening of the wounds. PH 1 stated a wound treatment nurse should be able to accurately document wound assessment, measurement and staging. PH 1 stated there was a certification course available for wound care nurses. PH 1 stated RNs should be utilizing NPUAP Guidelines as a resource and reference for wound assessment and staging. During a review of the National Pressure Ulcer Advisory Panel article, Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, copyright 2014, the article indicated, Stage 1 Pressure Injury: Non-blanchable erythema (redness) of intact skin Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis (the layer of skin just below the surface tissue) . The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible . Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer . The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed .Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location .Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister . This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic (dead) tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). During a review of the facility's policy and procedure (P&P) titled, Pressure Injuries/Skin Breakdown- Clinical Protocol, last revised April 2018, indicated, Assessment and Recognition: 1. The nursing staff should assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, weight loss, and history of pressure ulcers. 2. If a skin issue is noted the nurse should describe and document/report the following: anatomical location, stage, size, (length, width, and depth), sinus tracts, undermining, presence of exudates or drainage, necrotic tissue, (slough/eschar), granulation, and epithelial tissue, skin surrounding the wound; pain, resident's mobility status, current treatments, and active diagnoses that may impact skin. During a review of the National Institute of Health National Library of Medicine article, The Prevention and Management of Pressure Ulcers in Primary and Secondary Care, dated April 2014, the article indicated, The measurement of pressure ulcer size can be used by healthcare professionals for recording and monitoring the progression and healing of a pressure ulcer. Recording this accurately can allow an assessment to be made as to whether a treatment is effective in promoting healing, by reducing the size of the pressure ulcer. It is important for healthcare professionals to understand that a pressure ulcer does not only affect the visible skin but that it also has a cavity underneath it with depth and volume. As well as the visible cavity, a cavity under the skin that cannot be directly observed (undermining) may be present. This would need to be considered in addition to any measurement of visible damage.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedure (P&P) designed to prevent contamination of food during preparation and storage when: 1. Two kitchen staff did not wear hair nets in the kitchen. 2. The facility's dry storage room contained cans of food with no use-by date. 3. The facility's refrigerator had bloody red meat dated 10/18/23, with no indication of what the date meant. These failures placed residents of the facility at risk to consume outdated food and to develop food borne illness. Findings: 1. During an observation on 10/23/23, at 10:15 a.m., in the facility kitchen, the Kitchen Manager/Registered Dietitian (RD) and the facility cook (Cook 1) were not wearing hair nets. During a review of the facility's policy and procedure (P&P) titled, Personnel: Personal Hygiene and Appearance Policy No. 210, undated, indicated, Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent their hair from contacting exposed foods. During a review of the facility's policy and procedure (P&P) titled, Personnel: Personal Hygiene and Appearance, Policy No. 210, undated, indicated, Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent their hair from contacting exposed foods. 2. During an observation (during the initial tour of the kitchen) on 10/23/23, at 10:15 a.m., with the Kitchen Manager and [NAME] 2, in the facility's kitchen, the following undated cans were in the facility's dry storage area: two seven-pound cans of diced tomatoes; one seven pound can of mandarin oranges; one seven pound can of fruit cocktail. During an interview on 10/24/23, at 1:15 p.m., with the facility's Infection Preventionist (IP), the IP stated the undated canned goods should have a use by date. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Non-Food Supplies, (Policy 510), dated 2014, the P&P indicated, Canned goods are removed from cardboard boxes and like items stored together with labels turned outward and marked with received date upon receipt. 3. During a concurrent observation and interview (during the initial tour of the kitchen) on 10/23/23, at 10:15 a.m., with the Kitchen Manager and [NAME] 2, the facility's refrigerator contained bloody meat in a metal pan, covered with plastic wrap, dated 10/18/2023, on the bottom shelf of the refrigerator. [NAME] 2 stated the meat had been placed in the refrigerator to thaw, and she must have written the wrong date on the meat label. During an interview on 10/24/23, at 1:15 p.m., with the facility's Infection Preventionist (IP), the IP stated thawing meat should have two dates: the date the meat was placed in the refrigerator to thaw, and the date the thawing should be completed. The IP stated if the meat was set in the refrigerator five days ago on 10/18/23, the meat should not be eaten but should be discarded. During a review of the facility's policy and procedure (P&P) titled, Food Service Management- Food Preparation: Meat, Poultry and Fish, (Policy No. 524), dated 2014, the P&P indicated, Recommended method of thawing frozen meat is in the refrigerator. This may take one to three days. Meat is not thawed at room temperature. Place thawing meat on leak-proof trays on the lowest refrigerator shelf. Date thawing meat with freezer pull date and with use-by date.