Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow policy requirements of the facility policy titled, Weight
Assessment & Interventions for one of twelve residents sampled by not reweighing Resident 13 (R13) when
weight loss was discovered. The failure to follow the policy requirement affected one resident creating the
potential for additional unaddressed weight loss and a detrimental clinical outcome for residents.
Residents Affected - Few
Findings:
The facility policy titled, Weight Assessment & Interventions was reviewed. Under the policy section titled,
Weight Assessment numeral 3 states, Any weight change of 5 pounds more or less since the last weight
assessment will be retaken the next day for confirmation. According to the policy, over 3 months a weight
loss of greater than 7.5% is significant.
Resident 13 was admitted on [DATE] with diagnoses that included Alzheimer disease.
On 4/15/2025 at 10:30 AM, during a concurrent interview with the Director of Nursing (DON) and record
review of weight documentation for Resident 13 (R13) was performed. The documented weight on 2/2/2024
was 132 pounds. The weight on 3/3/2024 had dropped to 125 pounds for a total loss of 7 pounds. The
recorded weight loss was more than required for a reweigh. The DON provided documentation of weights
for R13 and stated that, The weight should have been retaken for March (3/3/24) because it was more than
5 pounds per policy. The DON confirmed, There should be another weight for the next day on the sheet
(Vital Signs Grid). The CNA's (Certified Nursing Assistants) do the weights and write them in. They should
have done it again the next day.
During an interview with CNA 3 on 4/17/2024 at 3:30 PM, CNA 3 stated, The residents are weighed on
Sundays. If they are below 5 pounds from the last time, we weight them again on Mondays. There aren't
many. When asked if R13 would have been reweighed on 3/3/2024, CNA 3 stated, If we know we do it.
On 4/18/2024 at 8:15 AM CNA 4 was interviewed regarding reweighing residents. CNA 4 stated, We get the
weights and when they are not right we reweigh then. Sometimes it is the chair. We weigh them first then
the chair after and subtract. If there is blankets it can make it wrong. CNA4 was not aware resident 13
needed reweighed on 3/3/2024.
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 4
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
04/18/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on interview, observation and record review, the facility failed to meet this requirement when a
medication for one (Resident 10) of nine sampled residents did not match Resident 10's current physician
order, and did not meet professional pharmacy standards of practice for drug labeling. This resulted in the
potential for overdosing medication and harm to the resident.
Findings:
Resident 10 was admitted to the facility in November, 2019 and was recently being treated with the
antibiotic Sulfametoxazole/trimethoprim (SMZ/TMP or Septra) for a urinary tract infection.
Review of the facility's policy titled, ER Medication Dispensing and Prescribing, revised 4/6/24, indicated
that Medications to be dispensed will be unit dose whenever possible . [Unit dosing is the pharmacy
practice of providing no more or no less medication than will be administered to the resident to lessen the
risk of under or overdosing].
A review of the facility's record titled, prescribing order dated 7/22/22, indicated that the facility's physician
ordered 400 millligrams (a unit of measure) of sulfamethoxazole/80 milligrams of trimethoprim in a single
dose.
In an observation on 4/16/24 at 11:00 AM, Licensed Vocational Nurse (LVN 1) was observed taking
Resident 10's medication from a blister pack (pre-packaged medication doses in individual plastic bubbles
on a multi-dose card) labeled SMZ/TMP DS TAB 800/160, indicating 800 milligrams of sulfamethoxazole,
160 milligrams of trimethoprim tablets. The tablets were provided in a form that was double the dose to be
administered to Resident 10, requiring the nurse to split the tablet in half, therefore the medication was not
unit dosed per pharmacy policy. The package was not labeled by pharmacy with the new dose, and
handwriting in blue ball point pen indicated, 1/2 tablet, 400mg/80mg.
In an interview on 4/16/24 at 1:32 PM, Director of Nursing (DON) stated that staff cannot re-label
medications on the blister pack; pharmacy must label all medications. DON stated that it is not an
acceptable practice to re-write dose changes by handwritten instructions.
In a telephone interview on 4/16/24 at 1:00 PM, Pharmacy Consultant (PC) stated that the facility's blister
pack medication is designed to be dose-specific and contain the dose to be delivered to the resident to
avoid medication errors, and that the best practice is for pharmacy to provide a pharmacy-printed label
according to the current dose. PC stated that only pharmacy technicians or pharmacists can re-label
medications and red alert stickers are to be used to note dosing changes.
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
04/18/2024
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 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on observation, interview, and record review, the facility failed to submit the required Payroll Based
Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS). The failure
to submit the required data, staffing hours and census information, can prevent determining whether or not
an adequate level of staff is working at a given time, leading to inadequate care of residents and adverse
clinical outcomes.
Findings:
On 04/18/24 at 10:10 AM, the PBJ reporting data was reviewed with the Facility Administrator (FA). FA
stated, I am not sure who is doing it. It maybe the Director of Nursing (DON). The DON was present and
stated, I believe it is done in payroll. It is not nursing that has that information. Human Resources was also
present and added that, It is not being done in HR.
On 04/18/24 at 10:15 AM, the PBJ reporting data was reviewed with the Accounting Clerk (AC). AC stated,
We don't submit this. I think it is nursing. I have not done it before.
There was no evidence offered by the facility that the facility was in compliance with submitting the PBJ
data and report to CMA, as required by regulation.
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
04/18/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, this regulation was not met when the facility failed to have a program
in place to prevent an outbreak by testing their water for legionella bacteria, (Legionaire's Disease, a
potentially fatal lung infection).
Residents Affected - Many
This had the potential for residents, staff and visitors to become infected with legionella bacteria and cause
illness and possibly death.
Findings:
In an interview and concurrent record review on 4/15/24 at 1:23 PM, Maintenance Manager (MM) provided
the facility's water testing logs from a professional testing laboratory. MM stated that he was unaware of a
requirement to test for or prevent legionella. Review of a record titled Analytical Report water monitoring
dated 2/5/24, indicated that testing was done for coliform and e. Coli (two bacteria from sewage that can be
present in water), but legionella testing was absent. MM confirmed that legionella was not listed on the
vendor's report of tests performed on the water. Similarly, a contracted laboratory's microbiology testing
report for the facility, dated 2/2/24 did not indicate testing for legionella. Similarly, review of a record titled,
County Water District report 2022 indicated no legionella testing was performed at the municipal source of
the facility's water.
In an interview on 4/17/24 at 1:30 PM, Facility Administrator (FA) stated that she was unaware of
requirement for Legionella/Management and water testing or that this was required by the Centers for
Medicare and Medicaid Services (CMS).
In a follow-up interview and concurrent record review on 4/17/24 at 11:35 AM, MM stated that he will
develop a written plan for legionella prevention and can add testing to current water testing being done by a
lab for the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555221
If continuation sheet
Page 4 of 4
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 18, 2024 survey of SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF?
This was a inspection survey of SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF on April 18, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SURPRISE VALLEY COMMUNITY HOSPITAL D/P SNF on April 18, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide enough food/fluids to maintain a resident's health."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.