Southern Inyo Hospital D/p Snf

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings: During an interview on April 27, 2026, at 8:23 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there are times when an RN is not available. LVN 1 further stated there are about two or three full-time RN staff available overall in the facility. During an interview on April 28, 2026, at 1:33 PM, with the Director of Staff Development (DSD), the DSD stated the facility does not consecutively have a registered nurse scheduled for eight consecutive hours a day, seven days a week. The DSD further stated there are currently total of three full-time registered nurses, but they are not always available…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 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. Findings: 1a. During a review of Resident 1's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (condition where the body does not use insulin properly, causing high blood sugar) with diabetic neuropathy (type 2 diabetes that has caused nerve damage) and primary osteoarthritis (condition where the cartilage in the joints slowly wears down over time). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. For three Residents (Resident 3, 28 and 4), the facility did not implement Enhanced Barrier Precautions (EBP- infection control measures for nursing homes, requiring staff to wear gowns and gloves during high-contact care to stop the spread of infection) specifically for residents with multidrug-resistant organism (MDROs- bacteria and other microorganisms that have developed resistance to multiple classes of antimicrobial drugs, making them difficult to treat), indwelling catheter (medical instruments designed to remain inside the body for a prolonged period), or chronic wounds. These failures had the potential to result in cross-contamination (spread…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 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). This failure had potential to cause medication administration error (preventable events from inappropriate medication administer) from IV delivery methods between IV push (IVP-a rapid, direct injection of medication into a vein) and IV piggy back (IVPB-slow medication administration into a vein), and incompatible solution mixture, which could negatively affect Resident 28's health from reduced medication effectiveness, local reddening, pain at the site, and lead to actual physical harm.Findings: During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 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 . She also stated I was sick 3 weeks ago with Flu- Coughing, sneezing, wheezing, weakness, fatigue, body aches, nasal congestion and fever. The IPN (Infection Preventionist Nurse) tested me for covid,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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. Findings: During a review of Resident A ' s History and Physical (H&P), the H&P indicated, Resident A is a [AGE] year old male with medical histories which included epilepsy (neurological disorder characterized by recurrent, unprovoked seizures [sudden burst of abnormal electrical activity in the brain which can cause a wide range of symptoms depending part of the brain]), severe intellectual disabilities, and diabetes (medical condition that…

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

Based on observation, interview, and record review, the facility failed to ensure 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. Findings: During an observation on July 11, 2024, from 8:00 AM, through 10:00 AM, there was no RN working in the unit. During an interview on July 11, 2024, at 11:10 AM, with the Assistant Director of Nursing (ADON) 1, the ADON 1 stated that besides the Director of Nursing (DON) 1 as an RN, they have two other RNs (RN 1, RN 2). The ADON 1 claimed that there was no RN scheduled for today, and the facility was aware of the policy…

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

Based on observation, interview, and record review, the facility failed to 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. Findings: During a concurrent observation and interview on July 8, 2024, at 02:08 PM, in the kitchen, Kitchen Aide (KA) 1 was not wearing a hair net while preparing food. When pointing out the absence of a hair net on, she then walked to the kitchen entrance and put on a hair net. KA 1 stated she should have put a hair net on, and the facility have said many times that staff are to wear hair net while in the kitchen. During an interview on July 12, 2024, at 11:07 AM, with the Dietary Services Supervisor (DSS) 1, the DSS stated staff should wear the hair net due to potential contamination of food, equipment, or utensils. During a review of the facility's policy and procedure (P&P) titled, Hair nets & personal permitted in FNSD (Food and Nutrition Services Department), dated September 2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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. Findings: During a concurrent interview and record review on [DATE], at 11:10 AM, with the Assistant Director of Nursing (ADON) 1, and the Director of Staff Development (DSD) 1, CNA 1's file, undated, was reviewed. There was no CPR's certification on file. The ADON 1 and DSD 1 explained that when CNA 1 was hired on [DATE], the facility failed to check if the CNA 1 had a CPR card. The DSD 1 further stated that for the last six months, he has not kept track of the staff CPR certification status. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of resident 27's admission Record (which contains demographic and medical information), indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses that included elevated white blood cell count, abnormality of albumin (a protein in your blood plasma), insomnia (difficulty falling asleep, staying asleep, or both), and weakness. During a concurrent observation and interview on July 8, 2024, at 4:14 PM, Resident 27's right elbow was observed in wound dressing. Resident 27 stated, she got a cut from a sharp edge of her bedrail. Upon closer inspection, the right-side bedrail's far end was found to have sharp…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 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. Findings: During an observation on Resident 1, on January 4, 2024, at 12:15 PM, in Resident 1's room, Resident 1 was lying in bed with the head of the bed elevated. A review of Resident's 1's admission Record (a document that gives summary of the resident's information) indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses that included dementia(a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood disturbance (feeling of distress or sadness, or symptoms of depression and anxiety), and anxiety(feeling of fear,…

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

Based on observation, interview, and record review, the facility failed to ensure 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. The facility's failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food-borne illness to a population of 28 immuno-compromised (decreased ability to fight off infections and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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. Findings: During a review of Resident 24's admission Record (contains demographic information), indicated, Resident 24 was admitted to the facility on [DATE], with a diagnoses included dementia (loss of cognitive functioning with thinking, memory which affects a person's daily activities), current pathological fracture of vertebrae and depression . During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: During a review of Resident 10's admission Record (clinical record of resident's admission information) indicated, Resident 10 was admitted on [DATE]. During a concurrent observation and interview with Resident 10, on May 16, 2023, at 4: 42 PM, Resident 10 was awake alert, able to verbalize her needs. Resident 10 stated, she uses six to seven regualr cigarettes per day. During a review of Resident 10's admission Smoking Safety Evaluation, dated June 3, 2022, at 6:46 PM, indicated, Resident 10 utilizes tobacco. During a review of Resident…

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