Health inspection·August 8, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **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 occurs when the body either does not produce enough insulin or cannot effectively use the insulin it produces). During a review of Resident A ' s Basic Interview for Mental Status (BIMS—a standardized assessment tool used primarily in healthcare settings, particularly nursing homes and other long term care facilities, to evaluate a resident ' s cognitive or thinking function), Resident A ' s BIMS score is 99, which indicates that the responses were incomplete and cannot provide baseline information about Resident A ' s cognitive function. During a record review of Resident ' s B H&P, the H&P indicated that Resident B is a [AGE] year-old female with medical diagnoses of multiple sclerosis (chronic autoimmune disease that affects the central nervous system and spinal cord, dementia (decline of cognitive function), anxiety disorder, and major depressive disorder. During a record review of Resident ' s B BIMS score, Resident B ' s BIMS score is 14, which indicated normal cognitive function. During a phone interview on August 19, 2024, at 12:03 PM, with Certified Nurse Assistant 1 (CNA1), CNA 1 stated Resident A was observed hovering on Resident B kissing. CNA 1 then approached Resident A and Resident B with CNA 2. CAN 1 stated, Resident A was then seen removing his hand from Resident B shirt and wipe his mouth. CNA 1 further stated, it was inappropriate for Resident A and Resident B (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555527 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)