Health inspection·November 6, 2023

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Based on observation, interview and record review the facility failed to ensure one of seven sampled residents (Resident 1), received care according to Resident 1's comprehensive person-centered care plan. This happened when Certified Nursing Assistant (CNA) 2 and CNA 3 had a verbal disagreement in front of Resident 1; CNAs did not exit the room when Resident 1 became agitated; CNA 3 provided care quickly with no breaks between tasks; three CNAs were in the room at the same time and CNAs did not provide a sheet to cover Resident 1 during care. This failure resulted in Resident 1 becoming increasingly agitated and had the potential to cause Resident 1 physical and psychosocial harm. Findings: During a review of facility policy and procedure titled, Resident Right-Resident Behavior and Facility Practice, dated 10/2020, indicated the resident has the right to be free from verbal abuse and the facility must care for residents in a manner and in an environment that promotes maintenance or enhancement fo each resident's quality of life and enhances dignity and respect in full recognition of his/her individuality which includes treating residents with respect. During a review of facility record, Job Description-Certified Nursing Assistant, dated 1/2019, indicated under the heading of General Competencies, the CNA always demonstrates a professional behavior when on duty and demonstrates a positve working relationship with patients visitors and facility staff. During a review of Resident 1's History and Physical, dated 10/26/2021 at 5:04 pm, indicated Resident 1 was admitted to the facility 10/25/2021. Resident 1 had a history of advanced dementia with minimal communicative skills, alcoholism, delusions, hallucinations, agitation and chronic back pain with arthritis and spinal compression fracture. Resident 1 had an increase in agitation, delusions and aggressive behaviors in March of 2021 and was brought to a hospital. Resident 1 stayed in the hospital for six months until a bed was available in the skilled nursing facility. During a review of Resident 1's Minimum Data Set (assessment of resident and care screening) dated 9/8/2023, indicated Resident 1 had unclear speech, severely impaired decision-making skills, disorganized thinking, inattention, short tempered and easily annoyed, delusions, physical behaviors (hitting kicking, pushing, grabbing) toward others and refused care. Resident 1 required at least 2-person physical assist for bed mobility, transfers, toilet use, personal hygiene and was dependent on staff for bathing. During a review of Resident 1's Progress Notes, dated 10/19/2023 at 11:54 am, indicated Resident 1's behaviors had improved with medication change but some staff noted behaviors of striking out. (continued on next page) 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 3 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 11/06/2023 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)