Health inspection·June 8, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and document reviews the facility failed to ensure licensed nursing personnel verified the skilled nursing unit residents' meals were appropriate according to their physician's order and matched the resident's meal tray ticket prior to receiving their meal. This failure had the potential to negatively affect the nutrition status of 23 out of 23 residents who have chronic medical conditions such as diabetes (inability to manage blood sugar levels), dysphagia (difficulty swallowing), heart disease, and other conditions by receiving an incorrect therapeutic diet meal, which may further impair medical and nutrition status from weight loss, weight gain, and other complications. (Cross reference F801) Findings: During a test tray observation and interview with Foodservice Worker (FSW) 1, on 6/6/23, at 12 PM, on the skilled nursing unit, FSW 1 was in the hallway delivering meal trays to rooms A14 and A15. FSW 1 stated the normal practice for meal tray delivery was for him to serve the residents trays after he brought the meal tray cart to the unit from the kitchen. FSW 1 stated no one checks the trays before he delivers them to the resident. FSW further stated he checked the tray ticket name and verify the resident name on the door and with the resident inside the room to make sure the correct meal tray is served to the correct resident. During an observation and interview with FSW 2, on 6/7/23, at 9 AM, of the breakfast meal tray delivery, FSW 2 stated he delivers the meal trays to residents as soon as he pushes the meal tray food cart to the skilled nursing unit. FSW 2 stated the nursing staff does not check the meal trays before he serves them to the resident. FSW 2 stated he checks the meal tray ticket with the room name, then delivers the meal tray in the room to the resident. During an interview with Registered Nurse (RN) 1, on 6/7/23, at 10:03 AM, RN 1 stated kitchen staff serve food trays to the residents, except for residents that are on isolation precautions (precautions help prevent the spread of germs) or have aspiration (food, liquid, or other material enters a person's airway) risk. RN 1 further stated, kitchen staff check the name on the resident's room and matches it to the tray ticket name to ensure the right meal tray goes to the right resident. RN 1 explained, the licensed nurses do not check trays to ensure the residents are being served the correct diet that was ordered by the providers, but it was important for the residents to receive the correct therapeutic diet. During an interview with Certified Nursing Assistant (CNA) 1, on 6/7/23, at 10:10 AM, CNA 1 stated Page 1 of 11 555660 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the dietary service personnel serve the trays to the residents, and when the residents are finished eating, the dietary service personnel will remove the trays from the rooms, except if the resident is on isolation risk. During an observation and interview with Registered Dietician (RD) 1 and the Food Service Director (FSD) on 6/7/23 at 10:42 AM, the FSD stated the FSWs has always delivered the meals to residents in the skilled nursing unit. The FSD further stated it may be helpful for the nursing staff to check the meal trays for accuracy when they arrive on the unit. Review of the facility policy dated 2/22, titled 4A-Skilled Nursing Facility Department Policy # S4.2.46, Resident meals and food management, indicated .All meals must be delivered by ZSFG [[NAME] San Francisco General] dietary department staff. Nursing staff will ensure that each resident receives appropriate diet . Per the State of California, Health and Safety Code, sections 1275, 100275 and 131200, Title 22- 72311 (c) Nursing Service, Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure. 555660 Page 2 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical supplies were properly stored when expired blood collection tubes were found in the medication storage room. This deficient practice had the potential to cause unsafe and/or inappropriate use of medical supplies to residents. Findings: During an observation on [DATE], at 1:50 PM, with Registered Nurse (RN) 1, there were eight gray top and one light green top expired blood collection tubes found in a small plastic bin in the medication storage room. During an interview, on [DATE], at 2:14 PM, RN 2 said, the blood collection tubes are used for residents with orders for blood draw. RN 2 read the date on the tubes as [DATE] and stated, All are expired and should be tossed out. The ZSFGH ([NAME] San Francisco General Hospital) Clinical Laboratories Test Directory, under Specimen and Lab Test Procedures, indicated, .Clinical Laboratory: Laboratory Administration Date of Original: [DATE] Collection, Labeling and Delivery of Laboratory Specimens . III. PROCEDURE A. Collection and Labeling Specimens . 3. The collection tube or container required for collecting a specimen for individual tests is specified in the online Lab Manual. Use only containers with in-date expiration dates [www.testmenu.com/zsfglab/TestDirectory .accessed on [DATE]] 555660 Page 3 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and document reviews the facility failed to ensure full-time Dietetic Services oversight for sufficient hours to effectively carry out the day-to-day functions of safe dietetic operations to meet the nutrition needs of 23 residents according to standards of practice when: 1. A nourishment pantry room had dirty ceiling panels and a vent with gray lint blowing out, 2. Resident's ice cream cups were stored and comingled in the staff lounge freezer, 3. A pink substance found in the nourishment pantry room ice machine chute, 4. A full-time qualified Dietetic Nutrition professional did not work in the skilled nursing unit when the Registered dietitian (RD) worked eight to ten hours a week and the Registered Dietetic Technician (DTR) worked five and half hours a week, on average, in the skilled nursing unit. (Cross reference F 726 and F 812) Findings: 1. On 6/7/23 at 10:50 AM, a concurrent observation and interview in the nourishment pantry room with the Registered Dietitian (RD) 1 and Registered Dietitian Technician (DTR) was conducted. The RD acknowledged the ceiling panels had a lot of black and gray stains on them, along with debris hanging off both the panels and vent edges. Both the RD and DTR stated they were unaware of how often the ceiling panels and vent in the nourishment pantry room were cleaned. The RD stated she does not check the nourishment pantry room for food stock levels or cleanliness during work time on the unit. Per the 2022 Federal FDA Food Code, sections 4-601.11, 4-602.13 and 4-202.16, titled Clean - Non-Food Contact Surfaces, Non-food contact surface equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Hard to clean substances .Non-Food-Contact Surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 2. During an observation and interview with Licensed Charge Nurse (LN) 1, on 6/5/23, at 1:30 PM, in the skilled nursing unit staff lounge, the staff freezer had forty-five ice cream cups stored inside. LN 1 stated the ice cream cups were for the residents in case they ask for it. The freezer also had opened staff food stored along with the resident ice cream cups. LN1 stated this practice does pose an infection control issue. During an observation and interview, on 6/6/23, at 11:15 AM, in the staff lounge with RD 1 and the DTR, the RD 1 and DTR both stated they were unaware the residents ice cream cups were stored in the staff's freezer. RD 1 further stated the resident's food should not be stored with staff food because it poses an infection control risk. Both the RD 1 and DTR stated they do not check the 555660 Page 4 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0801 refrigerators or freezers for resident food in the skilled nursing unit. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy dated 2/22, titled 4a.SNF Resident meals and food management indicated .between meal snacks and beverages are prepared and delivered to the 4A-SNF by ZSFG [[NAME] San Francisco General] dietary department. The snacks and beverages are stored near the nurse's station and are available to the residents upon request . Residents Affected - Many Review of the facility policy dated 12/22, titled Patient food services. D5. Patient pantries indicated .FNS [Food and Nutrition Services] clean pantries according to cleaning schedule items include microwave, ice machine, countertops, and cooler. Engineering department is responsible for cleaning the ice machine to manufactures standards. EVS [Environmental Services Staff] is responsible for cleaning the floors and garbage cans. Unit staff accessing the pantry should maintain cleanliness of the pantry (cleaning up any spills etc.) 3. During an observation and interview on 6/6/23 at 1:00 PM with Environmental Services Supervisor (EVSS) and the environmental Services Technician (EVT) in the Nourishment room, it was observed that a pink substance was around the ice machine chute. It was stated by EVSS and EVT that the ice machine was last cleaned on 1/23 and is due to be cleaned again in 6/23, as it is only cleaned semi-annually. EVSS and EVT stated the ceiling panels had black dust on them could be replaced and/or cleaned. Per the 2022 Federal Food and Drugs Administration (FDA) Food Code, section 4-602.11, titled Equipment Food-Contact Surfaces and Utensils .Surfaces of .equipment contacting food .such as .ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms .the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those items of equipment . Per the 2022 Federal FDA Food Code, section 4-204.13, titled Ice and Food Dispensing, Dispensing Equipment, Protection of Equipment and Food, In EQUIPMENT that dispenses or vends liquid FOOD or ice in unpackaged form: (A) The delivery tube, chute, orifice, and splash surfaces directly above the container receiving the FOOD shall be designed in a manner, such as with barriers, baffles, or drip aprons, so that drips from condensation and splash are diverted from the opening of the container receiving the FOOD. (B) The delivery tube, chute, and orifice shall be protected from manual contact such as by being recessed. (C) The delivery tube or chute and orifice of EQUIPMENT used to vend liquid FOOD or ice in unpackaged form to self-service CONSUMERS shall be designed so that the delivery tube or chute and orifice are protected from dust, insects, rodents, and other contamination . Review of the policy revised 1/20 titled Ice machine, indicated .the ice machine should be cleaned semiannually according to manufacturer's guidelines . Review of the undated ice machine manufacturers guidelines titled [NAME] Symphony plus 12 series ice and water dispensers' operation and service manual, indicated .Periodic cleaning/descaling and sanitizing of [NAME]'s ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate . 4. During an observation and interview, on 6/6/23, at 11:00 AM, in the staff lounge with RD 1 and DTR, the RD 1 stated she is the designated Registered dietician for the skilled nursing facility and 555660 Page 5 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many has another Registered dietician covers for off days. RD 1 stated that they spend eight to ten hours a week in the skilled nursing facility, and work on the acute side of the hospital during the remaining hours of the week. RD 1 stated that once or twice a month they spend time checking the nutrition room for par levels. The DTR stated she worked 40 minutes a day in the skilled nursing facility and another 2 hours a week to join the interdisciplinary team meetings (a team meeting where multiple disciplines including doctors, nurses, therapist, social worker, dietician, family, and other departments to discuss the residents' plan of care), for a total of five to seven hours a week. During an interview with the Food Services Director (FSD), on 6/7/23, at 11:25 AM, the FSD stated the skilled nursing unit does not have a designated nutrition services manager of dietetic operations. The FSD stated she was unaware of the unsanitary food safety practices in the skilled nursing unit. Per the 2019 California Retail Food Code chapter 3, titled Management and Personnel, Article 1. Supervision section 113945, The .person in charge .is present at the .facility during all hours of operation .section 113947, .the person in charge .has knowledge of safe food handling practices . as they relate to the specific food preparation activities that occur at the food facility. Review of the facility job description document dated 11/24/15, titled City and County of San Francisco Dietitian #2624 indicated, .Examples of Important and Essential Duties 2. Supervises food service to .patients .supervises food handling, sanitation, and cleaning procedures . 555660 Page 6 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. expired foods were found in two walk-in refrigerators located in the main food production kitchen and basement food service kitchen, 2. ceiling panels and an air vent in the nourishment pantry room were dirty with large gray and black stains, and thick gray lint particles were hanging out, 3. resident foods were not stored separately from staff foods, and 4. a pink sticky substance was found inside the rim of the ice machine chute located in the nourishment pantry room. These failures had the potential to expose 23 of 23 residents to harmful contaminants that could cause foodborne illness. (Cross reference F 801) Findings: 1. During an observation and interview, on 6/5/23, at 10:10 AM, in a main kitchen walk-in refrigerator, with Executive Chef (EXC) and Foodservice Director (FSD), expired milk cartons were found with the use by date of 6/4/23. The EXC stated these milk cartons should have been taken out of the fridge and unavailable for use. The FSD acknowledged the milk cartons were expired and should have been thrown out. During an observation and interview with the EXC, on 6/5/23, at 11 AM, in the basement kitchen walk-in refrigerator, a large metal pan on a food cart with other prepared foods, was found with cooked ground meat and a use by date of 6/4/23. The EXC stated that the ground meat should not be in the refrigerator and should have been thrown out. During an observation and interview, on 6/5/23, at 11:30 AM, in the kitchen with the FSD, it was observed that a bottle of black pepper was on the shelf available to use with an expiration date of 5/30/23. Per the FSD, this bottle should have been thrown away and a new bottle should have been opened and labeled. Per the 2022 Federal Food and Drugs Administration (FDA) Food Code section 3-602.11, titled Food and Dating labeling, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 Code of Federal Regulation (CFR) 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . Per the 2022 Federal FDA Food Code section 3-501.17, titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, .refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES . 555660 Page 7 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0812 Level of Harm - Minimal harm or potential for actual harm 2. During an observation and interview, on 6/5/23, at 1:15 PM, in the Skilled Nursing Unit nourishment pantry room with Licensed Nurse (LN) 1, it was observed the ceiling panels and vents had brown stains with dust, and the vents had thick gray lint particles blowing out. Additionally, a brown substance was found on most of the floor. LN 1 acknowledged the brown substance on the floor and stated it was from a coffee spill. LN 1 further stated the ceiling panels and vents should be clean and not have stains or dust on them. Residents Affected - Many During an interview with the Environmental Services Supervisor (EVS) and Environmetal Services Technician (EVT) on 6/6/23 at 1:00 PM in the nourishment pantry room, the EVS stated the ceiling panels and vents had not been cleaned in awhile and should be replaced. During an observation and interview on 6/6/23 at 10:50 AM in the nourishment pantry room with RD 1 and DTR, the RD stated she was unaware of the dirty ceiling panels and vent with dust and thick gray lint. The RD stated the panels and vents should be clean because it could affect the food stored in the pantry. Per the 2022 Federal FDA Food Code, sections 4-601.11, 4-602.13 and 4-202.16, titled Clean - Non-Food Contact Surfaces, .Non-food contact surface equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.Non-FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 3.During an observation and interview, on 6/5/23, at 1:30 PM, in the Skilled Nursing Unit staff lounge with LN 1, there were forty-five ice cream cups for residents stored in the staff freezer alongside staff foods. LN 1 stated this freezer is where they keep the resident's ice cream because there are no other freezers on the unit. LN 1 further stated this practice does pose an infection control issue. During an observation and interview, on 6/6/23, at 10:50 AM, in the staff lounge with Registered Dietician (RD) 1 and Registered Dietician Technician (DTR), the RD 1 stated the resident's ice cream cups should not be stored with the staff's food in the freezer due to potential food safety concerns. 4. During an observation and interview, on 6/6/23, at 1 PM EVS and EVT in the Nourishment room, a pink substance was found around the inside of the ice machine chute. The EVS and EVT both stated the ice machine was last cleaned in January 2023 and is due to be cleaned again June 2023, as it is cleaned semi-annually. Per the 2022 Federal FDA Food Code section 4-602.11, titled Clean - Food Contact Surfaces, Equipment food contact surfaces shall be cleaned at any time during the operation because any contamination may have occurred. Per the 2022 Federal FDA Food Code, section 4-204.13, titled Ice and Food Dispensing, Dispensing Equipment, Protection of Equipment and Food, In EQUIPMENT that dispenses or vends liquid FOOD or ice in unpackaged form: (A) The delivery tube, chute, orifice, and splash surfaces directly above the container receiving the FOOD shall be designed in a manner, such as with barriers, baffles, or drip aprons, so that drips from condensation and splash are diverted from the opening of the container 555660 Page 8 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many receiving the FOOD. (B) The delivery tube, chute, and orifice shall be protected from manual contact such as by being recessed. (C) The delivery tube or chute and orifice of EQUIPMENT used to vend liquid FOOD or ice in unpackaged form to self-service CONSUMERS shall be designed so that the delivery tube or chute and orifice are protected from dust, insects, rodents, and other contamination . Review of the facility policy revised 1/20, titled Ice machine, indicated .the ice machine should be cleaned semiannually according to manufacturer's guidelines. Review of the ice machine manufacturers guidelines tilted .[NAME] Symphony plus 12 series ice and water dispensers' operation and service manual (undated), indicated .Periodic cleaning/descaling and sanitizing of [NAME]'s ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate . Review of the policy titled Patient food services. D5. Patient pantries revised 12/22, indicated FNS clean pantries according to cleaning schedule items include microwave, ice machine, countertops, and cooler. Engineering department is responsible for cleaning the ice machine to manufactures standards. EVS is responsible for cleaning the floors and garbage cans. Unit staff accessing the pantry should maintain cleanliness of the pantry (cleaning up any spills, etc . Review of the facility policy revised on 11/19, titled Food and nutrition services. Section: production, purchasing, storage .dating and labeling food, indicated .foods sealed by the manufacturer are labeled by them with a date beyond which the food should not be consumed. These foods are discarded on that date. Spices are dry goods placed in rotation are good for six months. Month labels will be placed on items reflecting a date six months out from the time it is placed in rotation. Discard items no later than the end of the designated month . Review of the undated policy titled 4a.SNF Resident meals and food management indicate that between meal snacks and beverages are prepared and delivered to the 4A-SNF by ZSFG dietary department. The snacks and beverages are stored near the nurse's station and are available to the residents upon request . Review of the facility policy dated 12/22, titled Patient Food Services, indicated .unit pantries are stocked and rotated by FNS staff .FNS staff checks .foods .nourishment pantry food list does not contain ice cream cups . 555660 Page 9 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the failed to implement their infection prevention and control program when the personal protection equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace illnesses) cart was in close contact with two linen hampers containing soiled linens. Residents Affected - Few This facility failure has the potential for the spread of infection to residents and staff. Findings: A review of the Physician notes dated 6/6/23, indicated, Resident 1 requires contact isolation for the duration of skilled nursing course due to Extended-Spectrum Beta-Lactamases (ESBL, produced by bacteria's resistant to many of the antibiotics that are use to treat infections). According to the CDC Guidelines for Isolation Precaution, retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html, on 8/9/18, .Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ' s environment . During observation with the Director of Staff Development (DSD), on 6/6/23, at 3:31 PM, outside Resident 1's room, the PPE cart was placed beside the two hampers filled with soiled linens. During concurrent interview, the DSD acknowledged the PPE cart was in close contact with two hampers containing filled with soiled linens. The DSD stated, I just turned my back and this happens and removed the two hampers filled with soiled linens away from the PPE cart. A review of the facility Policy and Procedure titled, ZSFGH SNF Skilled Nursing Facility Infection Control Plan dated 11/16. indicated, Purpose: To establish and maintain infection control program designed to provide s safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . 555660 Page 10 of 11 555660 06/08/2023 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record record review, the facility failed to have a full time Infection Preventionist designated for the facility. Residents Affected - Many The facility failure has the potential for the lack of oversight to the infection control prevention and control program. Findings: During an interview on 6/7/23, at 2:34 PM, Infection Preventionist (IP) stated, I am the Infection Preventionist for the whole hospital, both for the Skilled nursing facility and the general acute care part of the hospital. I spend five to ten hours a week in the skilled nursing facility. During an interview on 6/8/23, at 7:42 AM, Registered Nurse (RN) 3 was unable to identify the IP for the SNF. During an interview on 6/8/23, at 7:45 AM, RN 4 was unable to identify the IP for the SNF. During an interview on 6/8/23, the Medical Director and Director of Nursing acknowledged the facility has no full time IP designated for the Skilled Nursing unit. A review of the undated facility document titled, Orders by Department and Patient indicated, Resident 2 was on vancomycin (used to treat infection) for psoas (muscles located in the lower back, the hip and thigh bone) abscess (infection), Resident 3 was on erythromycin (used to treat infection) ophthalmic (eye) ointment and moxifloxacin (used to treat infection) ophthalmic solution for conjunctivitis (eye infection), Resident 4 was on bacitracin (use to treat skin infection) ointment for wound care, Resident 5 was on cefazolin (used to treat infection) for bacteremia (presence of bacteria in the blood) , Resident 6 was on ciprofloxacin (used to treat infection) for osteomyelitis (inflammation or swelling that occurs in the bone, can result from an infection) and bacitracin for wound care . Resident 1 and Resident 7 were both in contact precaution for Extended-Spectrum Beta-Lactamases (ESBL, produced by bacteria resistant to many of the antibiotics that are use to treat infections. According to the Centers for Medicare and Medicaid Services (CMS) Updated Guidance for Nursing Home Resident Health and Safety released on 6/29/22, The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility. (https://www.cms.gov/newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety) 555660 Page 11 of 11