Health inspection·May 8, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/7/25 at 11:00 a.m., with the Director of Nursing (DON), DON confirmed Resident 51's CP was not revised to include a rash on the ankle. 2. During a review of Resident 57's clinical record, Resident 57 was admitted to the facility on [DATE] with diagnosis that included stroke and left sided weakness, difficulty swallowing, and pressure ulcer on the tail bone. During a record review of Resident 57's, Skin and Wound Evaluation, dated 5/2/25, the Skin and Wound Evaluation indicted that Resident 57 had skin damage to the tail bone. During a record review of Resident 57's CP, dated 3/15/25, the CP indicated that Resident 57 did not have any skin breakdown. During an interview on 5/8/25 at 11:00 a.m., with the DON, DON confirmed the CP was not revised to include the skin breakdown on Resident 57's tail bone. 3. A review of Resident 157's admission Record indicated Resident 157 was admitted to the facility on [DATE], with diagnoses of dementia, (affects memory, thinking and social abilities) bed confinement status (unable to tolerate any activity out of bed), and pain. A review of the most recent Minimum Data Set (MDS, a resident assessment tool), for Resident 157, dated 4/19/25, indicated that Resident 157 had a severe cognitive deficit (poor memory and decision making skills), with a brief interview for mental status (BIMS) score of 00 out of 15. A review of Resident 157's admission Record, dated 5/8/25, indicated that the Resident's daughter was the Responsible Party, indicating Resident 151 is unable to make healthcare decisions for herself. During a review of Resident 157's Physician's Orders on 5/8/25, indicated she was on comfort care (provides relief from symptoms and stress of a serious illness for the terminally ill). During a review of Resident 157's Care Plans on 5/8/25, indicated that a care plan was not created for Resident 157's physician ordered comfort care. During a concurrent care plan review and interview with the DON on 5/8/25 at 10:15 a.m., the DON confirmed that a care plan for the comfort care order for Resident 157 was not developed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 2 of 5 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 05/08/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food was stored, prepared and served under sanitary conditions when: Residents Affected - Many 1. Stainless-steel prep area was unsanitary 2. Large mixer was difficult to sanitize 3. Walk-in freezer had ice build-up 4. Coffee station was uncleanable 5. Kitchenware had burnt-on food 6. Painted center island were difficult to sanitize 7. Painted wood cabinets were difficult to sanitize 8. Ceiling above the stove was damaged 9. Area above laminate splash guard was difficult to sanitize 10. Kitchen and dishwashing room walls were dirty 11. Dry storage entryway was uncleanable 12. Dry storage shelving was uncleanable 13. Dry storage area ceiling was damaged 14. Divider wall had broken tile 15. Stainless-steel storage table was uncleanable 16. Dishwashing room wall was uncleanable These failures had the potential to spread infection and cause food borne illness for residents consuming food in the facility. Findings: A review of a facility document titled, Infection Control- Dietary, undated, indicated, All kitchenware .shall be cleaned after each use and thoroughly cleaned after each meal preparation. A review of a facility document titled, Infection Control- Dietary, undated, indicated, Non-food contact surfaces of equipment shall be cleaned to such intervals as to keep them in a clean and sanitary condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 3 of 5 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 05/08/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1. During an observation and concurrent interview on 5/5/25 at 11:19 a.m., the stainless-steel prep area had a small painted wood ledge with dried food debris, dried fluid debris and hair, and chipped paint, with wood exposed. The painted wood legs were with chipped, worn paint. The sealant between the stainless steel counter-top and abutted stainless steel counter-top (creates an L-shaped stainless steel counter-top) had dirty build-up and was stained. Dietary Supervisor (DS) confirmed these issues can be an infection control issue. 2. During an observation and concurrent interview on 5/5/25 at 11:20 a.m., a large metal mixer was noted to have chipped paint. DS confirmed this is a potential infection control issue because bacteria and food could get lodged between the metal and chipped paint. 3. During an observation and concurrent interview on 5/5/25 at 11:20 a.m., the walk-in freezer was noted to have ice build-up at the back of the condenser, on the condenser pipe, on the fan guard, on the ceiling, and on the floor. The DS stated she does inventory and cleaning of the freezer everything Tuesday and Wednesday. She indicated she cleans up the ice on Tuesdays. DS confirmed the danger of slipping and falling, and a possible malfunction of the unit, which could create an infection control issue. 4. During an observation and concurrent interview on 5/5/25 at 11:23 a.m., an observation of the coffee station noted the laminate edges of the top counter were chipped or missing, and uncleanable. The body and doors of the wood cabinet had edges and sides with chipped, worn paint. DS confirmed that these conditions could cause an infection control issue because bacteria could be present and paint chips could get into the food. 5. During an observation and concurrent interview on 5/5/25 at 11:24 a.m., an observation of two muffin tins, two cake pans, one large pot, and six out of eight sheet pans had burnt-on food present. The muffin tins had burnt-on food on the top, and the cake pans, large pot, and sheet pans had burnt-on food on the sides. DS confirmed that the burnt-on foods could cause an infection control issue. 6. During an observation and concurrent interview on 5/5/25 at 11:54 a.m., an observation of the center island noted edges of cabinet doors and drawers with chipped, worn paint. The left cabinet door is missing a part of the top edge, with chipped and worn paint. DS confirmed these conditions are difficult to clean and are an infection control issue. During an interview with the Maintenance Supervisor (MS) on 5/5/25 at 2:41 p.m., he indicated that he was aware of the condition of the kitchen and the walk-in freezer, but they were low on the priority list. He confirmed that the condition of the kitchen and freezer can potentially be an infection control issue. 7. During an observation and concurrent interview on 5/7/25 at 8:15 a.m., an observation of wood cabinets to the left and right of the stove noted cabinet and door edges to have chipped and worn paint, with exposed wood and is uncleanable. The drawer beneath the left wooden cabinet also with chipped and worn paint. The Dietary Manager (DM) confirmed that these conditions can hide bacteria and cause an infection control issue. 8. During an observation and concurrent interview on 5/7/25 at 8:16 a.m., an observation of the ceiling above the stove noted an open, chipped and unpainted area, exposing ceiling materials. DM confirmed a potential infection control issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 4 of 5 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 05/08/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 9. During an observation and concurrent interview on 5/7/25 at 8:17 a.m., an observation of the area above the laminate splash guard noted orange discoloration which could harbor bacteria. DM confirmed the potential infection control issue. 10. During an observation and concurrent interview on 5/7/25 at 8:22 a.m., an observation of the kitchen and dishwashing room walls noted grimy, dark areas, streaks, and old repairs. DM indicated the kitchen and dishwashing room have not been painted in years and the build-up of grime can potentially be an infection control issue. 11. During an observation and concurrent interview on 5/7/25 at 8:35 a.m., an observation of the dry storage entryway noted peeling paint in three spots. DM confirmed peeling paint could cause an infection control issue. 12. During an observation and concurrent interview on 5/7/25 at 8:36 a.m., an observation of the dry storage shelving, both metal and wood, noted chipped, worn paint and exposed wood. DM confirmed wood and paint particles can create an infection control issue. 13. During an observation and concurrent interview on 5/7/25 at 8:37 a.m., an observation of the dry storage ceiling with water damage. DM indicated it happened about a year ago. DM confirmed not sure what could be hidden under the damage, for instance mold, creating an infection control issue. 14. During an observation and concurrent interview on 5/7/25 at 11:26 a.m., an observation of the dividing wall of the dishwashing area and kitchen had two broken perimeter tiles. DM confirmed that bacteria and insects could be harbored, proper cleaning is not possible and can cause an infection control issue. 15. During an observation and concurrent interview on 5/7/25 at 12:53 p.m., the stainless-steel storage table had rust on the bottom shelf and on the legs. DS confirmed cleaning is not possible and can potentially cause an issue for infection control. 16. During an observation and concurrent interview on 5/7/25 at 12:46 p.m., an observation of the dishwashing room wall noted laminate cracked and repaired but some of the wall was still exposed, and laminate was cracked along the top of stainless-steel splash. There was also exposed sheet rock to the right of the dishwasher. DM confirmed these areas would be hard to clean and can cause an infection control issue. During an interview with the Infection Preventionist (IP) on 5/7/25 at 1:52 p.m., he confirmed that there are potential infection control issues with the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555221 If continuation sheet Page 5 of 5