Health inspection·May 12, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm called benzodiazepines). Documentation from the acute care hospital indicated the medications were picked up from their pharmacy ad were stapled shut with the patient's identification sticker and placed in the patient's belonging bag. The transport team reported they never opened the belongings bag and were not aware it contained medications. A review of the staff drug tests included one nurse who tested positive for opiates and benzodiazepines but negative for oxycodone. Residents Affected - Few During an interview on 4/27/23 at 10:25 am, IDON A said she no longer worked at the facility, but recalled Resident 1 had been sent out to a hospital and returned to their facility around 7:30 pm. The Skilled Nursing Facility (SNF) night shift Licensed Nurse (LN) A put the narcotics in the bottom of the medication cart. She said although the medication cart itself is locked, narcotics are supposed to be kept under double lock and there was a separate locked area within the medication cart where they were supposed to be placed. The narcotics, which were supposed to be sealed, since they had come from the pharmacy in the hospital where Resident 1 had been treated, were not counted. She said the narcotics should have been counted when the resident was brought back to the facility by the ambulance. IDON A said in the morning the count was done and it was off by four tablets of Lorazepam and Oxycodone each, if she recalled correctly. She was notified and a drug test was done on staff who had worked and may have had access to the medications. She said there was a Registered Nurse (RN) on the acute side of the facility for the emergency room (ER), RN A who tested positive for opioids and benzodiazepines but this nurse later produced a prescription for Tylenol with codeine and said she had a dental procedure and received a benzodiazepine medication. She said she never did found out where the drugs were or who took them. LN A was terminated and had issues other than the ones involved with not counting the narcotics. She said she filed a report with CDPH, DEA (Drug Enforcement Agency) and the Sheriff. During an interview on 5/2/23 at 5 pm, RN A said she was working in the ER and LN A was working in the SNF when Resident 1 returned to the facility. She said she opened the front door for the ambulance and then opened the ER door for Resident 1's daughter. She said she did not have anything else to do with Resident 1. She said all of Resident 1's medications and belongings were given to LN A and she did not even even know what was given to him. RN A said she takes care of ER patients and does not get involved with the SNF residents. She said she later found out some of the narcotics were missing and she was drug tested. RN A said her drug screen tested positive for benzodiazepines but she had received Valium (a benzodiazepine that can be detected weeks after the last dose) in a procedure she had recently, and it can be detected in a drug screen for two months after ingestion. She said she also had a prescription for Tylenol with codeine (shows as opiates during a drug screen). She said her drug screen was negative for oxycodone. RN A said she left to take a traveling assignment for three months but has since returned to work at the facility. During an interview on 5/1/23 11:50 am, the Administrator (Admin) said staff who had access to the medications were tested and RN A tested positive for opiates and benzodiazepine. Admin advised RN A of the test results who provided a prescription for Tylenol with codeine. RN A later said she had eye surgery two weeks prior and had received valium at that time which could stay in her system and account for the positive benzodiazepine drug screen. RN A provided a record of the procedure, (done 10/5/22) as well as the medication she had received. Admin said they never did find the narcotics and don't know what happened to them. She said LN A was let go because there were a lot of complaints that he was rude to other employees, unprofessional and did not count these narcotics, when he knew he should have done so because it's in our policies. Admin said Resident 1 received her medications as needed so there was no issue with the resident being deprived of her medication. She said two RNs now count, like we're supposed, to from each shift. The narcotic sheets were requested for the Oxycodone and the Lorazepam. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 2 of 4 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 555221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surprise Valley Community Hospital D/P Snf 741 N. Main Street Cedarville, CA 96104 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few narcotic sheet for the Lorazepam was provided which indicated there were 26 tablets when first counted. The Oxycodone narcotic sheet could not be located at this time. During a follow up interview on 5/3/23 10:40 am, the Director of Staff Development (DSD) said she had looked through all narcotic sheets and could not find the one for the oxycodone. She said this was the only one missing. Admin also confirmed she was unable to find it. Based on interview and record review, the facility failed to track controlled substances (medications that have a high risk for abuse such as opioid medications) when facility staff failed to count the medications upon receipt for one resident (Resident 1) and failed to keep a narcotic sheet for the oxycodone. This resulted in a discrepancy in the number of pills received for two controlled medications, oxycodone (a controlled narcotic mediation) and Lorazepam (anti-anxiety medication) and resulted in a lack of accountability for these medications and possible diversion of the controlled substances by staff. Findings: The facility's Controlled Substance policy, dated 4/2019, was reviewed. The policy statement was, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. 1. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on the premises. 3. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. 4. Access to controlled medications remains locked at all times and access is recorded. Upon receipt: a. The nurse receiving the medication and the individual delivering the medication verify the name. dose and quantity of each controlled substance being delivered. b. Both individuals sign the controlled substance record of receipt. c. An individual resident controlled substance record is made for each resident who is receiving a controlled substance. The record contains: (1) name of the resident; (2) name and strength of the medication; (3) quantity received; (4) number on hand; (5) name of physician; (6) prescription number; (7) name of issuing pharmacy; and (8) date and time received. The facility's Accepting Delivery of Medications policy, dated 2/2021, was reviewed. The policy statement was, All staff shall follow a consistent procedure in accepting medications. 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt. A review of Resident 1's record indicated she was admitted on [DATE] with diagnoses that included severe dementia, anxiety, and depression. She suffered a fall and fracture (break) of her left femur (thighbone) and was transferred to an acute care hospital for treatment. She returned to the facility on [DATE] around 7:30 pm. The California Department of Public Health (CDPH) received notification on 10/18/22, from the Interim Director of Nurses (IDON) A that there were missing narcotics and staff were being drug tested. The facility indicated four tablets were missing of Oxycodone and Lorazepam (in a class of drugs called benzodiazepines). Documentation from the acute care hospital indicated the medications were picked up from their pharmacy and were stapled shut with the patient's identification sticker and placed in the patient's belonging bag. The transport team reported they never opened the belongings bag and were not aware it contained medications. A review of the staff drug tests included one nurse who tested positive for opiates and benzodiazepines but negative for oxycodone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 3 of 4 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 555221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surprise Valley Community Hospital D/P Snf 741 N. Main Street Cedarville, CA 96104 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/27/23 at 10:25 am, IDON A said she no longer worked at the facility, but recalled Resident 1 had been sent out to a hospital and returned to their facility around 7:30 pm. The Skilled Nursing Facility (SNF) night shift Licensed Nurse (LN) A put the narcotics in the bottom of the medication cart. She said although the medication cart itself is locked, narcotics are supposed to be kept under double lock and there was a separate locked area within the medication cart where they were supposed to be placed. The narcotics, which were supposed to be sealed, since they had come from the pharmacy in the hospital where Resident 1 had been treated, were not counted. She said the narcotics should have been counted when the resident was brought back to the facility by the ambulance. IDON A said in the morning, the count was done and it was off by four tablets of Lorazepam and Oxycodone each, if she recalled correctly. She was notified and a drug test was done on staff who had worked and may have had access to the medications. She said there was a Registered Nurse (RN) on the acute side of the facility for the emergency room (ER), RN A who tested positive for opioids and benzodiazepines but this nurse later produced a prescription for Tylenol with codeine and said she had a dental procedure and received a benzodiazepine medication. She said she never did found out where the drugs were or who took them. LN A was terminated and had issues other than the ones involved with not counting the narcotics. She said she filed a report with CDPH, DEA (Drug Enforcement Agency) and the Sheriff. During an interview on 5/2/23 at 5 pm, RN A said she was working in the ER and LN A was working in the SNF when Resident 1 returned to the facility. She said she opened the front door for the ambulance and then opened the ER door for Resident 1's daughter. She said she did not have anything else to do with Resident 1. She said all of Resident 1's medications and belongings were given to LN A and she did not even even know what was given to him. RN A said she takes care of ER patients and does not get involved with the SNF residents. She said she later found out some of the narcotics were missing and she was drug tested. RN A said her drug screen tested positive for benzodiazepines but she had received Valium (a benzodiazepine that can be detected weeks after the last dose) in a procedure she had recently, and it can be detected in a drug screen for two months after ingestion. She said she also had a prescription for Tylenol with codeine (shows as opiates during a drug screen). She said her drug screen was negative for oxycodone. RN A said she left to take a traveling assignment for three months but has since returned to work at the facility. During an interview on 5/1/23 11:50 am, the Administrator (Admin) said staff who had access to the medications were tested and RN A tested positive for opiates and benzodiazepine. Admin advised RN A of the test results who provided a prescription for Tylenol with codeine. RN A later said she had eye surgery two weeks prior and had received valium at that time which could stay in her system and account for the positive benzodiazepine drug screen. RN A provided a record of the procedure, (done 10/5/22) as well as the medication she had received. Admin said they never did find the narcotics and don't know what happened to them. She said LN A was let go because there were a lot of complaints that he was rude to other employees, unprofessional and did not count these narcotics, when he knew he should have done so because it's in our policies. Admin said Resident 1 received her medications as needed so there was no issue with the resident being deprived of her medication. She said two RNs now count, like we're supposed, to from each shift. The narcotic sheets were requested for the Oxycodone and the Lorazepam. The narcotic sheet for the Lorazepam was provided which indicated there were 26 tablets when first counted. The Oxycodone narcotic sheet could not be located at this time. During a follow up interview on 5/3/23 10:40 am, the Director of Staff Development (DSD) said she had looked through all narcotic sheets and could not find the one for the oxycodone. She said this was the only one missing. Admin also confirmed she was unable to find it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 4 of 4