Health inspection·April 1, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin for one of one residents (Resident 1) sampled for abuse. Resident 1 was found to have significantly large suspicious bruising on both of her breasts from an unknown cause. The facility had not reported this to the California Department of Public Health (CDPH), Ombudsman (Resident advocate agency), or to their local Law Enforcement agency, in accordance with their Abuse Policy. This failure resulted in the inability for CDPH, Ombudsman and Law Enforcement to gather additional information surrounding Resident 1's injuries and conduct their own investigation, which could negatively impact Resident 1's physical, emotional and psychosocial well-being and quality of life. Findings: A review of facility's policy provided by Director of Nursing (DON) titled, Elder Abuse dated January 2012, indicated abuse as the, willful infliction of injury .resulting in physical harm, pain, or mental anguish. Facility policy further indicated it would identify events such as suspicious bruises on patients .that may constitute abuse and determine the direction of the investigation. Facility policy indicated the facility would investigate alleged incidents and complete an SOC 341 form (a form used to report suspected elder abuse to the Ombudsman and CDPH), notify the Ombudsman, local Law Enforcement and call the Department of Health Services Licensing and Certification (CDPH), no later than two hours after the allegation is made. Then complete a written investigation report in writing to the Ombudsman, State Survey Certification Agency, and any other agency according to law. During a record review of Resident 1 ' s admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included failure to thrive (decline in overall health, including weight loss, decreased appetite, and reduced physical function stemming from various underlying medical or psychosocial issues), and dementia (loss of memory, language, and other thinking abilities that are severe enough to interfere with daily life). A record review of Resident 1's, Wound, Skin Tear or Bruise Investigation Report dated 8/20/24, completed by Registered Nurse (RN) A indicated, Multiple bruises with different stages found [on Resident 1's breasts] during shower. Possible self-picking? RN A documented that, nursing interventions were to monitor until resolved. A record review of Resident 1's, Nursing Narrative Note Final Report dated 8/20/24 5:03 pm, written by RN A, indicated a Certified Nursing Assistant (CNA), reported that resident has multiple bruises on her breast and her right hand. Assessed resident [Resident 1's] body. Multiple bruises with (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 04/01/2025 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)