Average — CMS composite of the measures below.
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Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southern Inyo Hospital D/p Snf during CMS and state inspections, most recent first.
RN staffing was not provided for at least 8 consecutive hours a day, 7 days a week. An LVN stated there were times when no RN was available, and the DSD confirmed the facility did not consistently schedule an RN every day, including weekends. Record review showed multiple days with no RN listed on the staffing report, and the DON stated the facility had difficulty maintaining RN coverage and had no policy addressing RN staffing.
Smoking Materials Left in Residents' Possession: A resident on oxygen was observed with multiple lighters on the nightstand, and three other residents were also found with cigarettes or lighters in their rooms or pockets. Care plans identified smoking-related needs such as supervision, smoking safety assessments, and tobacco-use interventions, but staff confirmed residents kept their own smoking materials. The DON reviewed the Smoking Safety Policy, which requires smoking supplies to be stored securely by nursing staff rather than kept in residents' personal possession.
The facility failed to keep its infection control program updated annually and did not implement EBP for three residents with indwelling catheters. The IP stated the annual review was not documented, and staff interviews showed confusion about EBP, with no EBP policy in place, no PPE carts or EBP posters outside the residents’ rooms, and standard precautions posted instead of EBP.
A resident with dementia, hydronephrosis, urinary retention, and CKD received Rocephin via IV after the DON used medication from the EKIT. The physician’s order for ceftriaxone 1 gram IV daily did not specify the exact method of administration between IVP and IVPB or the diluting agent, and the DON confirmed the order was not clarified before the antibiotic was prepared and infused.
Multiple staff and residents experienced respiratory symptoms following prolonged water leaks and the presence of black material, suspected to be mold, on ceilings in several facility areas. Despite repeated reports, maintenance actions were limited and mold testing was not performed by a specialist, contrary to facility policy. Two residents developed pneumonia and several staff reported ongoing symptoms, with environmental hazards persisting over several months.
Two residents engaged in inappropriate sexual contact under the supervision of facility staff. A male resident with epilepsy and intellectual disabilities was seen kissing a female resident with multiple sclerosis and dementia. The incident was witnessed by two CNAs, who reported it to a registered nurse. The facility failed to adhere to its policy on resident rights, which aims to protect residents from abuse and neglect.
The facility did not maintain the required RN staffing levels, failing to have an RN onsite for at least eight hours a day, seven days a week, from April to July 2024. Observations and interviews confirmed multiple days without RN coverage, violating the facility's policy.
A kitchen aide was observed preparing food without a hair net, contrary to facility policy, which could lead to food contamination. The Dietary Services Supervisor confirmed the requirement for staff to wear hair nets to prevent contamination.
The facility failed to ensure that five CNAs maintained current CPR certification, as required by policy. The oversight was due to a lack of verification and tracking by the ADON, DSD, and DHR, potentially impacting resident care during emergencies.
A resident sustained an abrasion on her right elbow due to sharp edges on her bedrail, which was not reported to management. The LVN treated the wound but did not report the incident, and both the DON and Environmental Services Manager were unaware of the issue. The facility's policy requires maintaining equipment in safe condition, which was not followed.
RN Not Scheduled 8 Hours Daily and 7 Days Weekly
Penalty
Summary
The facility failed to ensure that the services of a registered nurse (RN) were provided for at least eight consecutive hours a day, seven days a week. During an interview, an LVN stated there were times when an RN was not available and that there were only about two or three full-time RN staff overall in the facility. The DSD stated the facility did not consecutively have an RN scheduled for eight consecutive hours a day, seven days a week, and that although there were three full-time RNs, they were not always available on weekends. During record review, the facility's Skilled Nursing-Per Patient Day report for August 7, 2025, through August 31, 2025, showed no RNs listed on August 7, August 10, August 11, August 23, August 24, August 30, and August 31. The DSD confirmed the facility did not schedule an RN seven days a week during that period. The DON stated the facility had difficulty finding RN coverage consistently as required by federal regulations and that the facility did not have a policy addressing RN staffing.
Smoking Materials Left in Residents' Possession
Penalty
Summary
The facility failed to ensure a safe environment and failed to implement interventions to prevent accidents related to smoking for four sampled residents. The deficiency involved Residents 1, 4, 11, and 29, whose smoking materials were observed in their rooms and in their personal possession rather than being maintained in accordance with the facility's Smoking Safety Policy. The report states that these failures had the potential to result in serious injury, including burns, fire hazards, or harm to residents, staff, and the facility environment. Resident 1 was observed sleeping in bed with oxygen running via nasal cannula, while four lighters were on the nightstand. LVN 1 confirmed the lighters belonged to the resident and stated he was a lighter hoarder who kept multiple lighters in his room. Resident 1's record showed an order for PRN oxygen at 2L via nasal cannula for decreased O2 saturations, and the care plan identified him as a current tobacco, marijuana, and vape user who was able to light his own cigarettes but needed supervision when smoking. LVN 2 confirmed Resident 1 was a smoker and kept his cigarettes and lighters in his possession. Resident 4 was observed in bed with a pack of cigarettes on the nightstand, and she confirmed the cigarettes belonged to her and that she smoked two to three times a week. Resident 11 was observed pulling a lighter from his jean pocket and stated he always kept his lighters with him; his care plan stated he was able to safely use a lighter. Resident 29 had a lighter on the bedside table and stated he was a smoker and always kept his lighters. His smoking and safety assessment noted tobacco use and balance problems while sitting or standing, and his care plan stated he required supervision while smoking. LVN 2 stated nursing staff were not in charge of keeping residents' smoking materials, and the AD stated only one resident's smoking materials were kept by staff while other smokers kept their own materials. The DON reviewed the Smoking Safety Policy, which stated residents may not keep cigarettes, lighters, matches, or any smoking supplies in their personal possession and that smoking materials are to be stored securely by nursing staff; the DON stated the policy was not followed.
Infection Control Program Not Updated and EBP Not Implemented for Residents With Indwelling Catheters
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program because its infection control policies were not updated on an annual basis. The Infection Preventionist stated that the infection control policies are to be updated annually, but during record review the facility could not provide documented evidence that the infection control program had been reviewed within the last year. The facility’s Infection Prevention and Control Plan, dated December 2024, stated that the organization’s infection prevention and control plan shall be evaluated at least on an annual basis and whenever risk significantly changes. The facility also failed to implement Enhanced Barrier Precautions for three residents who had indwelling catheters. Resident 3 was admitted with diagnoses including diabetes, dementia, and obstructive and reflex uropathy, and had a suprapubic catheter order. Resident 28 was admitted with diagnoses including dementia, hydronephrosis, and urinary retention, and had a foley catheter order. Resident 4 was admitted with diagnoses including active primary progressive multiple sclerosis, UTI, and sialolithiasis, and was observed with a suprapubic catheter. For each of these residents, observations showed no PPE cart and no EBP poster outside the room, and the green flag indicating standard precautions was posted above the door. Staff interviews showed a lack of understanding and implementation of EBP. The Charge Nurse stated there were no residents on TBP or EBP and confirmed that the three residents with indwelling catheters all had green flags above their doors. CNA staff stated EBP did not sound familiar or did not ring a bell, and an LVN stated he thought staff were supposed to gown up for EBP but was not sure what it was. The DON stated the facility did not have an EBP policy, and the Infection Preventionist stated the facility had not developed a policy for EBP and that the policy was not followed.
IV antibiotic administered without clarifying order details
Penalty
Summary
The facility failed to ensure a physician’s medication order was completed and administered in accordance with acceptable nursing standards of practice for one resident. Resident 28 was admitted with diagnoses including dementia, hydronephrosis, and urinary retention. During a medication administration observation, the DON was observed preparing 1 gram of Rocephin in a 100 mL bag of normal saline and attaching it to the resident’s IV access, with the infusion set at 200 mL per hour for a 30-minute delivery time. On concurrent interview and record review, the resident’s order for ceftriaxone sodium intravenous solution reconstituted 1 gram indicated to use 1 gram intravenously once daily for 3 days related to chronic kidney disease, but it did not specify the exact delivery method between IV push and IV piggyback or identify a specific diluting agent. The DON stated the antibiotic had not yet been sent by the pharmacy, so it was taken from the Antibiotic Emergency Kit, and confirmed the order did not include the exact delivery method or diluting agent. The facility’s IV Therapy policy required a physician’s order to include the medication name, dosage, route, frequency, and verification of the rate and method of infusion, and the DON stated the policy was not followed for the IV medication delivery method and diluting agent.
Failure to Maintain Safe and Sanitary Environment Due to Water Leaks and Suspected Mold
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by multiple reports and observations of water leaks and black material, suspected to be mold, on ceilings in several areas including the resident activity room, front office, control room, and the Assistant Director of Nursing's (ADON) office. Staff interviews revealed that these issues had been ongoing since at least November, with repeated reports to maintenance and management. Despite these reports, only limited action was taken, such as wiping the black material and removing some ceiling tiles, and mold testing was performed by maintenance staff rather than a specialist. The facility's own policy requires a hazard-free environment, but staff acknowledged that proper mold prevention and testing by a specialist were not conducted. Several staff members, including the ADON and others sharing affected office spaces, reported respiratory symptoms such as coughing, wheezing, sneezing, fatigue, and sinus issues, with some symptoms worsening after maintenance activities disturbed the black material. The Infection Preventionist Nurse (IPN) confirmed that multiple residents and staff developed respiratory symptoms during the same period, with two residents diagnosed with pneumonia and treated with antibiotics. COVID-19 testing was negative for these cases, and no mold exposure testing was performed. Observations confirmed the presence of water leaks and black stains on removed ceiling tiles, and staff reported ongoing concerns about the facility's response to these environmental hazards.
Inappropriate Resident-to-Resident Contact
Penalty
Summary
The facility failed to protect and prevent inappropriate resident-to-resident sexual contact between two residents, identified as Resident A and Resident B. Resident A, a male with epilepsy, severe intellectual disabilities, and diabetes, was observed by Certified Nurse Assistant 1 (CNA1) hovering over and kissing Resident B, a female with multiple sclerosis, dementia, anxiety disorder, and major depressive disorder. Resident A's Basic Interview for Mental Status (BIMS) score was 99, indicating incomplete responses and an inability to provide baseline cognitive function information. In contrast, Resident B's BIMS score was 14, indicating normal cognitive function. The incident was witnessed by CNA1 and CNA2, who observed Resident A removing his hand from Resident B's shirt and wiping his mouth after the inappropriate contact. Both CNAs reported the incident to a registered nurse, recognizing it as inappropriate. The facility's policy on resident rights, which emphasizes protection from abuse and neglect, was not adhered to, resulting in a failure to maintain a safe environment for the residents involved.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was available onsite for at least eight hours a day, seven days a week, from April 1, 2024, through July 11, 2024. During this period, there were 17 days when no RN was onsite, and on three days, the RN hours were less than the required eight hours. This deficiency was identified through observations, interviews, and record reviews. On July 11, 2024, it was observed that no RN was working in the unit between 8:00 AM and 10:00 AM. Interviews with the Assistant Director of Nursing (ADON) and the Director of Human Resources (DHR) confirmed the absence of an RN on that day and the facility's awareness of the staffing policy. Further record reviews revealed multiple instances of non-compliance with the RN staffing requirement across several months. In April 2024, there were no RN hours on six specific days, and one day had reduced hours. In May 2024, there were six days without RN coverage and two days with reduced hours. In June 2024, three days lacked RN presence, and in July 2024, two days were identified without RN coverage. The facility's policy, dated July 9, 2020, mandates RN presence for at least eight consecutive hours daily, which was not adhered to during the specified period.
Failure to Wear Hair Net During Food Preparation
Penalty
Summary
The facility failed to protect residents from potential food contamination when a kitchen staff member did not wear a hair net during food preparation. This incident involved a kitchen aide who was observed without a hair net while preparing food. Upon being informed of the oversight, the kitchen aide acknowledged the requirement and immediately put on a hair net. The Dietary Services Supervisor confirmed that staff are required to wear hair nets to prevent contamination of food, equipment, or utensils. The facility's policy, dated September 2023, mandates that all Food and Nutrition staff wear hairnets or other suitable coverings to confine hair and prevent contamination.
Failure to Maintain Current CPR Certification for CNAs
Penalty
Summary
The facility failed to ensure that nursing staff were certified and kept current in cardiopulmonary resuscitation (CPR) for five of 18 Certified Nurse Aides (CNAs). During a review of CNA 1's file, it was found that there was no CPR certification on file, and the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) admitted that the facility did not verify CPR certification upon hiring. Additionally, the DSD acknowledged that for the past six months, they had not tracked the CPR certification status of the staff. Further investigation revealed that three other CNAs (CNA 2, 3, and 4) did not have CPR cards, and one CNA (CNA 5) had an expired CPR card. The Director of Human Resources (DHR) stated that it was an oversight, assuming that CNAs had CPR certification before receiving their CNA certification. The facility's policy required all certified and licensed staff to hold current CPR certification, which was not adhered to, potentially affecting residents' care during emergencies.
Failure to Maintain Safe Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to maintain safe operating equipment for one of its residents, resulting in an injury. Resident 27, who was admitted with diagnoses including elevated white blood cell count, abnormality of albumin, insomnia, and weakness, sustained an abrasion on her right elbow due to sharp edges on her bedrail. During an observation and interview, Resident 27 reported that the injury was caused by the sharp edge of her bedrail, which was confirmed upon inspection. The incident was not reported to the facility's management by the LVN who treated the wound, and the Director of Nursing was unaware of the sharp edge on the bedrail. The Environmental Services Manager, filling in for the Director of Facilities, also stated he was unaware of the issue and that no report had been made. The facility's policy requires maintaining all essential equipment in safe operating condition, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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