F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to provide a Registered Nurse (RN) who was on
duty, eight hours out of every day, seven days a week. This failure had the potential for RN assessment
skills and supervision to not be available every day for residents and staff.
Findings:
Record review of the staffing schedules for the months of August and September 2023 showed there was
no RN working on the following dates: 8/5, 8/6, 8/19, and 8/20; 9/2, 9/3, 9/9, 9/10, 9/16, 9/17, 9/23, 9/24,
and 9/30.
During an interview, on 10/3/23, at 9:18 am, the Administrative Assistant stated they did not have a full-time
RN on the weekends during the months of August and September 2023.
During an interview, on 10/4/23, at 10:23 am, the Director of Nursing stated they didn't have any policy
about nurse staffing or RN staffing.
During an interview, on 10/4/23, at 10:42 am, Licensed Nurse (LN) A stated RNs on the floor were
sporadic, they came and went.
During an interview, on 10/4/23, at 11:41 am, the Nurse Manager stated that for the last month they didn't
have an RN working on the weekends.
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 2
Event ID:
555420
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
10/05/2023
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 0880
Provide and implement an infection prevention and control program.
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 report a COVID-19 (a contagious virus that caused
respiratory illness) outbreak which affected four residents (Residents 5, 19, 43, and 45) and four staff
members to the California Department of Public Health (CDPH). This failure had the potential to expose
further residents to illness, which could have threatened their health and well-being.
Residents Affected - Some
Findings:
A facility policy, titled, Outbreak Investigation, revised 1/1/12, was reviewed. An outbreak was defined as an
excess level of endemic (constantly present in a specific location) disease or statistically (by the numbers)
significant increase in endemic level. The time period would have varied according to the infection. The
facility's threshold (required number of cases for an outbreak) was defined as greater than five percent of
the resident population. If an outbreak was confirmed, it should have been reported to the local county
Public Health Department and also to CDPH within 24 hours of the initial identification.
A review of Resident 5's record indicated they were admitted to the facility on [DATE]. Resident 5's
diagnoses included chronic obstructive pulmonary disease (COPD--a lung disorder) and pneumonia (a lung
infection). Resident 5 tested positive for the COVID-19 virus on 9/23/23.
A review of Resident 19's record indicated they were admitted to the facility on [DATE]. Resident 19's
diagnoses included COPD and heart failure (inability of the heart to pump adequately). Resident 19 tested
positive for the COVID-19 virus on 9/21/23.
A review of Resident 43's record indicated they were admitted to the facility on [DATE]. Resident 43's
diagnoses included COPD and heart failure. Resident 43 tested positive for the COVID-19 virus on 9/23/23.
A review of Resident 45's record indicated they were admitted to the facility on [DATE]. Resident 45's
diagnoses included dementia (a mental disorder that caused confusion and memory loss) and high blood
pressure. Resident 45 tested positive for the COVID-19 virus on 9/28/23.
Record review of the facility's census (number of residents) showed that from 9/21/23 to 9/28/23, there
were 48 to 49 residents. The number of positive COVID-19 cases (four), would have been approximately
eight percent of the facility's resident population at that time.
During an interview, on 10/3/23, at 1:42 pm, the Infection Preventionist (IP) stated the facility had four
residents who had tested positive for COVID-19 in September of 2023, and IP reported it to their county's
Public Health Department. Their county's Health Officer was also the facility's Medical Director. IP stated
they did not report it to CDPH. IP had been reporting outbreaks to CDPH and also via another network
reporting system, until recent changes in the reporting procedure were implemented. IP stated, We
absolutely did have an outbreak in September [2023].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555420
If continuation sheet
Page 2 of 2
