Surprise Valley Community Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Surprise Valley Community Hospital D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 8, 2025

  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: 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. […]

• No harm, potential for more than minimal, widespreadF851Apr 18, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF880Apr 18, 2024

  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). 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. […]

• No harm, potential for more than minimal, widespreadF656May 12, 2022

  Based on observation, interview and record review, the facility failed to ensure that 11 of 16 sampled residents (Residents 3, 4, 5, 7, 12, 11, 12, 14, 16, 21, and 22) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when; 1. Resident 4 was taking [MEDICATION(S)] (an antidepressant medication) and [MEDICATION(S)] (an antipsychotic medication) and a care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects, or… […]

• No harm, potential for more than minimal, widespreadF756May 12, 2022

  Based on interview and record review the facility's pharmacy consultant failed to identify drug irregularities which included duplicate therapy (According to the Centers for Medicare and Medicaid Services or CMS, Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking), the CMS requirement to limit as needed (PRN) antipsychotic (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking) and [CONDITION(S)] (any drug that affects brain activities associated with mental processes and behavior) medications to 14 days, unless there was a re-evaluation of… […]