Health inspection·May 18, 2023

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **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). Residents Affected - Few 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 review of Resident 24's clinical record titled, Nursing Progress Notes, by Licensed Vocational Nurse (LVN 1), dated April 23, 2023, at 1:07 PM, indicated, resident had a fall incident on April 19, 2023, and sent to emergency room for further evaluation. During a review of Resident 24's MDS, indicated, MDS SCSA Sections I (Active Diagnoses) and J (Health Conditions) were incomplete. During a concurrent interview and record with the Assistant Director of Nursing (ADON), on May 17, 2023, at 3:10 PM, Resident 24's MDS SCSA was reviewed. The ADON stated, the MDS SCSA should have been completed on May 8, 2023. The ADON further stated, it should have been completed within 14 days from the resident's fall incident. During an interview with the MDS Nurse on May 18, 2023, at 7:50 AM, the MDS Nurse stated, Resident 24's MDS SCSA was created on April 24, 2023, for the fall incident that resulted in a lumbar fracture. The MDS Nurse stated it should have been completed on May 8, 2023. The MDS Nurse further stated, the timeframes for completion and submission of assessments are based on the current requirements published in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessment and Reassessment, indicated, .A comprehensive reassessment shall be completed within 14 days after it is Page 1 of 5 555527 555527 05/18/2023 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0637 determined that there has been a significant change in the resident's physical or mental condition. Level of Harm - Minimal harm or potential for actual harm During a review of CMS RAI Version 3.0 Manual (helps nursing staff in gathering definitive information on a resident's strengths and needs), dated October 2019, indicated, An SCSA is appropriate when there is a determination that a significant change (either improvement or decline) in a resident's condition from his/ her baseline has occurred as indicated by comparison of the resident's current status . The ARD [assessment reference date] must be less than or equal to 14 days after the IDT's [interdisciplinary team] determination that the criteria for an SCSA are met (determination date + 14 calendar days). Residents Affected - Few 555527 Page 2 of 5 555527 05/18/2023 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: Residents Affected - Many 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 diseases) residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on May 15, 2023, at 11:18 AM, in the kitchen, one sink used for food preparation did not have an air gap. The CDM verified, the sink drainpipes did not have an air gap. The CDM stated, air gaps are important to ensure there is good water flow through the pipes and that water does not get stuck and backflow (water flowing back) or overflow. This could lead to contamination (dirty) of food and is an infection control issue. During a concurrent observation and interview with the Director of Materials Management (DMM), on May 16, 2023, at 11:34 AM, verified, there was no visible air gap under the food preparation sink and there was a risk for dirty water to backflow into the food preparation sink, which would contaminate the food preparation area. The DMM stated, the air gap needed to be added. During an interview with the Facility Director (FD), on May 16, 2023, at 2:56 PM, the FD stated, it was brought to his attention that the food preparation sink does not have a visible air gap. The FD stated, an air gap will need to be added. During a concurrent interview and record review, on May 16, 2023, at 3:00 PM, with the CDM, the facility's Policy and Procedure (P&P) titled, Backflow Preventers, dated October 2022, was reviewed. The P&P indicated, . Policy: to maintain a safe water supply from backflow .Procedure: . 5. PIC (person in charge) must demonstrate: identifying the source of water used and measures taken to ensure that it remains protected from contamination such as providing protection from backflow and precluding the creation of cross contamination (movement or transfer of harmful bacteria (germs) from one person, object or place to another) . The CDM stated, the P&P was not followed when there was no airgap in the kitchen sink. During a review of the FDA Federal Food Code 2022 5-202.13 indicated, .Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, 555527 Page 3 of 5 555527 05/18/2023 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow . 2. During a concurrent observation and interview with the Certified Dietary Manager (CDM) on May 15, 2023, at 11:20 AM, the bench can opener was noted to have old crusty food along the shank (blade of the can opener). The CDM stated, the can opener should not be dirty, and the current condition of the can opener placed the residents at risk for infection and food borne illnesses (nausea, vomiting, and/or diarrhea). The CDM stated, the expectation is that the can opener is cleaned after each use (if dirty) and the process is to manually wash the can opener with soap and water and then run it through the dishwater. During an interview with the Cook, on May 15, 2023, at 4:59 PM, the [NAME] stated, the bench can opener should be cleaned whenever dirty or twice a week, and the process for cleaning the can opener is to first manually clean with soap and water and then clean in the dishwasher. The cook further stated, there should never be caked on food on the can opener. During a concurrent interview and record review, on May 16, 2023, at 3:05 PM, with the CDM, the facility's Guideline titled, Cleaning Procedure #42 - Bench can opener, undated, was reviewed. The guideline indicated, the shank and top of the base (of the can opener) are to be cleaned and sanitized after each use .Remove shank of can opener- take to dish machine, air dry . The DM stated, the guideline for cleaning the can opener was not followed, because there was dry food on the shank. 555527 Page 4 of 5 555527 05/18/2023 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 10's Assessments on May 16, 2023, Smoking Risk Assessments were not completed . During a concurrent interview and record review on May 16, 2023, at 5:20 PM, with Licensed Vocational Nurse (LVN 2), Resident 10's SmokingRisk Assessments was reviewed. LVN 2 stated, Resident 10's Smoking Risk Assessments were not done quarterly as indicated in the facility's Smoking P&P. During a concurrent interview and record review on May 17, 2023, at 3:14 PM, with the Assistant Director of Nursing (ADON), the facility's P&P titled, Smoking, dated March 2019, was reviewed. The P&P indicated, .4. Smoking risk assessments are performed quarterly with recommended changes, which could affect the safety of the Resident. The assessments are reviewed by the interdisciplinary team (team members from different areas of practice working together with a common purpose) for agreement and planning of interventions, as needed. The ADON further reviewed Resident 10's Smoking Risk Assessments records and stated Resident 10's Smoking Risk Assessment was incomplete. The ADON stated, Smoking Risk Assessments should have been completed and documented quarterly. The ADON further stated, facility did not follow the Smoking P&P when the facility did not complete the Smoking Risk Assessments quarterly. 555527 Page 5 of 5