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🔎 Surprise Valley Community Hospital D-p Snf

Inspection Results


Inspection Overview

Surprise Valley Community Hospital D-p Snf has been cited for a total of 53 deficiencies since we began saving each survey.

In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2025-05-08
Correction Date: 2025-05-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-05-08
Correction Date: 2025-06-02
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-04-18
Correction Date: 2024-05-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-04-18
Correction Date: 2024-05-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Survey Date: 2024-04-18
Correction Date: 2024-05-06
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-04-18
Correction Date: 2024-05-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-12-28
Correction Date: 2023-12-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-12-05
Correction Date: 2023-12-18
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-05-12
Correction Date: 2023-05-18
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-05-10
Correction Date: 2023-05-18
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2022-05-12
Correction Date: 2022-07-13
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-01-18
Correction Date: 2022-02-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: C

Keep all essential equipment working safely.

Survey Date: 2022-01-12
Correction Date: 2022-02-08
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-09
Correction Date: 2021-03-03
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: B

Provide immediate access to any resident.

Survey Date: 2020-12-01
Correction Date: 2020-12-22
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2020-07-03
Correction Date: 2020-07-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2020-07-03
Correction Date: 2020-07-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2019-07-17
Correction Date: 2019-10-08
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: C

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: C

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2018-07-26
Correction Date: 2018-09-21
Category: Nursing and Physician Services Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**