Health inspection·December 5, 2023

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. Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse when Certified Nursing Assistant (CNA) 1 slapped Resident 1 in the face. This resulted in anger, frustration and emotional distress for Resident 1 and had the potential for all residents under the care of CNA 1 to be subjected to mistreatment. Findings: A review of the facility's policy titled, Identification Types of Abuse dated 5/25/22, indicated that, Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and suppo1t, and a facility-wide culture of compassion and caring. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. On 11/01/23 at 3:30 PM, during an interview Licensed Practical Nurse (LPN) stated, .I heard a sharp scream sound and then I heard his [CNA 1] voice, it was low and about four or five words, an angry voice. According to the LPN two other staff heard and investigated the scream. At that time they were not able to determine what occurred. The LPN went on to state, [Resident 1] came to the nurses station and motioned at him [CNA 1], which is totally out of her normal self and was yelling and waiving her arms around yelling, He hit me, he hit me and that's not right. He hit me right here and pointed to her neck. She is not normally so animated and she was so upset I separated them by taking her to the other nurses station. She kept saying, he gets so mad. He hit me hard. She was tearful and adamant that he [CNA 1], hit her. On 11/02/23 at 11:20 AM, in a concurrent interview and record review, the Director of Nursing (DON) stated, She [Resident 1] said she didn't want to do what he [CNA 1] wanted, and he slapped her. She said not with a fist, but open handed. She said he was trying to take her clothes off and she didn't want to so he slapped her. The whole time her story hasn't changed. She knew he slapped her on the left side of her face . The DON also provided photos taken about an hour after the incident which showed some redness to the left side of Resident 1's face. On 11/02/23 at 12:15 PM, Resident 1 was interviewed and stated, Yes, he slapped me on the face .on the side here. Pointing to the left side of her face. Resident 1 stated, it was a while back. (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: 555221 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 12/05/2023 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)