Health inspection·December 28, 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 prevent the willful neglect of one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 intentionally neglected to check Resident 1's blood sugars and administer insulin (a medication to lower blood sugar) as ordered by the physician, then LVN 1 falsified Resident 1's medication record by recording blood sugar results that she never obtained and insulin coverage that she never provided, nine times between November and December, 2023. This failure resulted in abnormal blood sugar levels requiring additional insulin to stabilize Resident 1's blood sugars and had the potential to have serious negative outcomes to Resident 1's health, by not monitoring and controlling his blood sugars with insulin. Findings: The facility's policy titled, Abuse Identification dated 5/25/22, was reviewed. The policy indicated that, Abuse is defined as: a. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and b. 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; and c. Having the knowledge and ability to provide care and services, but choosing not to, constitutes abuse. Resident 1 (R1), was admitted to the facility with a diagnoses that included diabetes and dementia. R1 required blood sugar monitoring four times daily and administration of insulin. A review of R1's Physician's Orders for the month of December 2023, reflected that R1's physican had ordered; a. Blood sugar checks three times a day before meals. b. Novalog (a regular fast acting insulin) 100 units (U-100)subcutaneous (SQ, just into the superficial fat layer under the skin), to be given per a sliding scale (SS- insulin is given according to the level of the blood sugar), as followed: for blood sugars between 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, 401-450 give 12 units (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 12/28/2023 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)