Southern Inyo Hospital D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to ensure the services of a registered nurse (RN) were provided for at least eight consecutive hours a day, seven days a week, for the facility. This failure had the potential to result in delays in clinical assessment, changes in resident conditions not being identified timely, and increased risk for adverse outcomes due to lack of RN oversight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment and implement interventions to prevent accidents related to smoking for four of 12 sampled residents (Residents 1, 4, 11, and 29), when smoking materials were not maintained in accordance with the facility's policy and procedure (P&P). These failures had the potential to result in serious injury, including burns, fire hazards, or harm to residents, staff, and the facility environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective, and active system wide infection control program for the prevention, control, and investigation of infections and communicable diseases for a universe of 23 residents, when: 1. The facility failed to keep its infection prevention and control policies updated annually. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's medication order was completed and administered in accordance with acceptable nursing standards of practice for one of 12 sampled residents (Resident 28), when nursing staff administered ceftriaxone sodium (Rocephin-an antibiotic used to treat severe infections) without clarifying the physician's order for the intravenous (IV) administration method and the appropriate diluting agent (liquid solution to mix medication). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public when four staff members complains of black material on ceiling and water leaks stains in the resident's activity room, front office, control room and ADON's (Assistant Director of Nursing) office. This failure has a potential to put residents, staff and visitors. health, safety and wellbeing at risk. Based on Interview with Licensed Vocational Nurse (LVN 1), on April 2, 2025, at 10:00 AM. LVN1 stated that there's water leak spots in some areas of the building, most especially in the activity room. LVN 1stated I have not seen the black materials on the ceiling, but our ADON has it in her office. I believe it has been reported to maintenance . [...]

Inspectors wroteBased on interview and record review, the facility failed to protect and prevent residents from an inappropriate resident-to-resident sexual contact for two of two residents (Resident A and Resident B) when Resident A was seen hovering over Resident B and kissing. This failure resulted in Resident A and Resident B engaging in resident-to-resident sexual contact while under the supervision of the facility ' s staff which had the potential to cause unsafe environment such as unsafe sexual activity that could negatively affect Resident A and Resident B ' s health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available onsite at least eight (8) hours a day, seven (7) days a week for all admitted residents from April 1, 2024, through July 11, 2024 when the facility did not have RN onsite for 17 days and had fewer RN hours than eight (8) hours requirement for three (3) days. This failure had a potential to negatively affect residents care from an oversight of RN which may increase risk of avoidable resident safety events such as medication errors or delayed in comprehensive assessment that could jeopardize residents' health, safety, and lead to actual harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from food contamination for a universe of 29 residents when one kitchen staff was not wearing a hair net during food preparation. This failure had the potential to contaminate food, equipment, and utensils.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were certified and kept current in cardiopulmonary resuscitation (first aid technique to help a person who has stopped breathing) for five (5) of 18 Certified Nurse Aide (CNA) (CNA 1, 2, 3, 4, and 5) when the facility was unable to provide documented evidence of current CPR certification. This failure had the potential to negatively affect residents' care due to unqualified or incompetent staff during emergencies at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe operating equipment for one (1) of 29 residents (Resident 27) when Resident 27's bedrail had sharp edges on it. This failure resulted in Resident 27 sustaining an abrasion on her right elbow from the sharp edges which may cause an infection and putting Resident 27's health in jeopardy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their post-fall protocol and prevention was implemented in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1) when Resident 1 had a fall incident on December 2, 2023. This failure had the potential to place Resident 1 at risk for further falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was no air gap (a separation between the water supply and potentially contaminated [dirty] water in a sink or other plumbing fixture) found at the food preparation sink. When installed and maintained properly, the air gap works to prevent drain water from backing up into the sink and possibly contaminating the area used for washing food.), which had the potential for back flow from the drain to contaminate the sink. This had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The bench can opener (counter mounted) had dried crusted food on the shank (blade) which could transfer to residents' foods. This had the potential to cause foodborne illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a computerized clinical assessment tool ) Significant Change in Status Assessment (SCSA-a comprehensive assessment that must be completed when the resident meets the significant change guidelines for either major improvement or decline) within 14 days, for one of six sampled residents (Resident 24) who was reviewed for a fall with fracture (broken bone) of first lumbar vertebra (backbone within the lower back). This failure had the potential to delay in identification and implementation of necessary interventions to address the resident's care and support needs.

Inspectors wroteBased on observation,interview and record review, the facility failed to follow their policy and procedure (P&P) for smoking for one of six sampled residents (Resident 10) when the facility did not perform a Smoking Risk Assessment of Resident 10. This failure had the potential to delay in identification and implementation of necessary interventions to address the resident's care and which could jeopardize the health and safety of the other residents in the facility.