Health inspection·December 5, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility did not protect residents' right to be free from sexual abuse for one of three sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 1, offered to have sexual relations with her to relieve stress. This caused fear and anxiety for Resident 1, and had the potential to negatively impact her emotional and psychosocial well-being. Findings: A review of the facility's policy titled, Elder Abuse dated 6/2023, indicated, Abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse of a patient includes the deprivation of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all patients, even those in a coma, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Instances include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse Includes, but is not limited to: · Sexual harassment. · Sexual coercion. · Sexual assault. · Non-consensual sexual contact of any type. Resident 1 was admitted to the facility with diagnoses that included Diabetes and weakness. Resident 1 was alert, oriented and able to make her own health care decisions. Resident 1 was able to engage in daily activities with minimal assistance. On 9/05/23, Resident 1's Minimum Data Set (MDS, an assessment tool), reflected a Brief Interview for Mental Status (BIMS, determines decision making (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 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 12/05/2023 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)