Health inspection·May 30, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Resident 1 was grumpy. She was brushing Resident 1's hair and pulled a large knot and Resident 1 started crying so she bent down and Resident 1 slapped her and said, you did that on purpose. CNA A's human resources file was reviewed on 5/3/23 at 1:15 pm with the Human Resources Director. CNA A had been disciplined on 10/29/22 for being aggressive and disrespectful towards staff members. Residents Affected - Few The facility's policy titled, Resident Rights - Resident Behavior and Facility Practice dated 10/2020, was reviewed and indicated, the facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life and enhances dignity and respect in full recognition of his/her individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555420 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 555420 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modoc Medical Center D/P Snf 228 W MC Dowell Ave Alturas, CA 96101 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their abuse policy and procedure when a Certified Nursing Assistant (CNA) A, who allegedly abused a resident (Resident 1), was not immediately removed from direct patient care during an abuse investigation. Residents Affected - Few This failure had the potential to place Resident 1 and other residents at risk for harm. Findings: A review of the facility's Elder Abuse policy indicated, Employees who are being investigated for alleged abuse will be either placed in a non-patient work setting or on administrative leave. The California Department of Public Health received a report from the facility on 3/15/23, which indicated CNA A was brushing Resident 1's hair when the brush hit a tangle and pulled her hair and Resident 1 slapped CNA A. Resident 1 alleged CNA A pulled her hair on purpose. This report did not indicate if CNA A had been suspended during the investigation. A review of Resident 1's record indicated she was admitted with diagnoses that included high blood pressure, diabetes, and heart disease. A review of her Minimum Data Set (MDS, a standardized resident assessment tool) dated 2/21/23, included a BIMS (brief interview for mental status) of 12 which indicated mild cognitive impairment. Resident 1 was able to understand and able to convey her needs. During an interview on 5/4/23 at 7:50 am, CNA A said she was getting Resident 1 up around 5 am on 3/15/23, and the resident was grumpy. She was brushing Resident 1's hair and pulled a large knot and Resident 1 started crying so she bent down and the resident slapped her and said, you did that on purpose. CNA A said she put the brush down and finished the rest of Resident 1's care, put away the hoyer lift and reported the incident to the charge nurse. She said she finished the rest of her shift which was about one hour then gave report and did rounds with the oncoming shift from 6:30 am to 7 am. CNA A said she was not put on Administrative (admin) leave. She said she asked about that and was told by the charge nurse that it was too late. CNA A said she did not come in contact with Resident A the rest of the shift. During an interview on 5/4/23 at 8:50 am, the charge nurse said Human Resources (HR) places staff on admin leave and the Chief Nursing Officer (CNO) or Director of Nurses (DON) was the one responsible for notifying HR about allegations of staff to resident abuse. She said CNA A was not placed on Admin leave. During an interview on 5/3/23 at 1:15 pm, the Human Resources Director (HRD) said an email was sent to the Risk Manager on 3/15/23 at 5:25 am, from their internal safety system, that included the details of the incident and indicated that CNA A was instructed to not come in contact with the resident or enter her room until after an investigation was conducted. An email on 3/16/23 at 8:59 am, from the CNO indicated it was he said/she said incident. HRD said she did not find out about this incident until 3/22/23. At that time she sent an email to the CNO on 3/22/23 at 10:57 am, and a follow up email at 11:10 am, wherein she advised the CNO that they put the employee on leave, even it was for just one day, until it could be determined that the incident was unfounded. HRD said CNA A should have been put on Administrative (admin) leave as is their usual protocol. She said even if the staff was off the schedule they should be placed on admin leave. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555420 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 555420 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Modoc Medical Center D/P Snf 228 W MC Dowell Ave Alturas, CA 96101 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The CNO sent an email to the Risk Manager on 3/22/23 at 11:06 am, in which he said there was no way to corroborate the incident so they were not going to put CNA A on admin leave. The email further stated that the abuse allegation was the resident against an employee and was more about Resident 1 slapping CNA A in the face while she was brushing her hair. During an interview on 5/8/23 9:45 am, the CNO said the night shift charge nurse called him the morning of 3/15/23. He said he waited until he got the social service's notes on 3/20/23 before he completed his five day report to the state but had already determined by 3/17/23 that he could not corroborate abuse. CNO said he did not notify HR because there was no reason to suspend CNA A because she was not on the schedule on 3/15 and 3/16 and by 3/17/23 (her next working day), he already concluded there was no abuse. He was asked if he thought there was any issue with the treatment Resident 1 received, assuming what CNA A said was true and that she had pulled Resident 1's hair when she was brushing it, and he said no. He said the incident was really more about Resident 1 slapping CNA A instead of the opposite. Event ID: Facility ID: 555420 If continuation sheet Page 4 of 4