Health inspection·April 2, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 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. Residents Affected - Some 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, and it was negative. I did not get tested for Mold exposure and we have few residents with respiratory symptom that started around February, and some were treated with antibiotics. Based on interview with Assistant Director of Nursing (ADON), on April 2, 2025, at 10:15 AM. ADON stated There's some Black Material/ Spot on the ceiling in my office, after the rain we had back in February, it got worse. One area in the ceiling were all black. I reported it to [NAME], our maintenance. He told me that he will get it tested for Molds. I have had a bad respiratory issue. I was coughing, wheezing, sneezing, and fatigue . ADON also stated. Maintenance was telling me that the result of the Mold testing has a low reading. He wiped all the BLACK stuff on the ceiling with a spray. He tested it after cleaning/wiping the black material. My respiratory symptoms got worse after maintenance wiped the black material off the tiles . Based on interview and concurrent record review of the Infection Control monitoring log with IPN (Infection Preventionist Nurse) on April 2, 2025, at 10:30AM. IPN stated Yes. We have had a few residents with respiratory symptoms. Two residents were diagnosed with Pneumonia and received antibiotics treatment. There were 7 residents with respiratory symptoms from February/March 2025. We did chest X-ray on all 7 residents, and we tested them for covid with negative results. We also have 10 staff with respiratory symptoms that started around February/March 2025 with sore throat, congestion, body aches and chills and 1 with fever . Based on interview with Staff 1, on April 2, 2025, at 10:45 AM. Staff 1 stated I'm in the same office with ADON. I've been having issues with my sinuses. I've seen the ENT specialist. Symptoms all started after the maintenance wiped the Black material /Spots off the ceiling. We relocated to a Page 1 of 2 555527 555527 04/02/2025 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some different area now. They contained that room. They removed the tiles that had the black material on it. We've seen that black discoloration from the ceilings since November and we reported to maintenance back in February 2025 . Based on interview with Maintenance on April 2, 2025, at 11:00 AM. Maintenance stated Yes. I received a report regarding the Black material in the ADON's office. We contained the area and relocated both ADON and STAFF 1. We already removed the tiles out from the ceiling, and we will replace it with a new one. I did a testing for presence of Mold and the report shows that it has a low reading When asked about the water leaks, Maintenance stated There's some water leaks in the activity room and front office and in the process of replacing the tiles. We have not tested it for molds. I can do the test myself; we don't have to call the Mold specialist to test it. We have the kit, and we can do it ourselves . Based on observation with Maintenance on April 2, 2025, at 11:15 AM, Noted water leak spots in the activity room's ceiling, front office and inside the control room. No black material/spots noted on the ceiling. Inside the ADON's office, noted some tiles had been removed from ceiling. Old Tiles that were removed had some black stained noted on it. No water leaks noted inside random' resident's room in the acute unit or Skilled facility Unit (SNF). Based on interview with Staff 2 on April 2, 2025, at 11:30AM, Staff 2 stated I've been complaining about the black material/Mold in the ceiling in the drug room. Every time it rains, it leaks. I've been e-mailing and reporting it to the maintenance, and nothing's being done. Management and Maintenance are aware of the Black material /water leaks in the buildings . Based on interview and record review of the policy's titled SAFE ENVIRONMENT with ADON on 4/2/2025 at 11:50 AM. Policy stated It is the policy of this facility to ensure the safety and wellbeing of residents by maintaining a hazard free environment 4. e. The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. When ADON was asked if the policy was followed, she stated it is not a comfortable environment due to not having a Specialist on Mold Prevention and Treatment , doing the proper testing for the presence of mold in the facility for the safety and wellbeing of our residents, staff and visitors . 555527 Page 2 of 2