Inspection·April 17, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to meet this requirement when an expired food product was stored in the refrigerator and available for serving to residents. This had the potential to result in foodborne illness and poor food palatability (flavor, freshness). Findings Review of the facility's policy titled, Food Storage Policy and Procedure dated 2005 indicated, All food should be labeled and dated, and Refrigerated food should be stored upon delivery and careful rotation procedures should be followed. On 4/14/25 at 12:00 PM, a 15-ounce spray can of Redi Whip whipped topping was observed in the facility's foodservice refrigerator, with a use by date of 2/24/25 written per the facility's policy. It was observed that the product was nearly two months beyond this use-by date. In a concurrent interview on 1/14/25 at 12:00 PM, Dietary Manager (DM) confirmed that the whipped topping, Should have been thrown away. DM was observed disposing of the item. 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 04/17/2025 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)

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 observation, interview, and record review, the facility failed to follow infection control standards for 4 out of 5 residents (Resident 1, Resident 28, Resident 19, and Resident 29) during medication pass when staff did not disinfect medical equipment and when medication containers where brought into residents' rooms and handled by the residents. Residents Affected - Few This had the potential to spread a communicable disease and cause cross-contamination. Findings: The facility's policy titled, Cleaning of Non-Critical Patient Care Equipment, dated 05/2017, indicated the purpose of this policy is to provide guidance on cleaning and disinfection of non-critical, patient care equipment. It is the policy for patient care equipment to be cleaned and disinfected to prevent the potential spread of infection and cross-contamination. The facility's policy titled, Medication Preparation and Administration, revised 2010, indicated this policy is to ensure the most complete and accurate implementation of a physician's medication orders and to optimize drug therapy by administering drugs in an accurate, safe, timely and sanitary manner. A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include dementia (impairment of memory, thinking and social abilities), hypertension (pressure in your blood vessels is too high), and renal insufficiency (poor function of the kidneys). Review of the most recent Minimum Data Set (MDS, a resident assessment tool), for Resident 1 dated 2/28/25, indicated that Resident 1 had a moderate cognitive deficit, with a brief interview for mental status (BIMS) score of 8 out of 15. During an observation on 4/16/25 at 7:11 am, Licensed Vocational Nurse (LVN) 1 took the blood pressure of Resident 1. Once finished, LVN 1 then placed the blood pressure cuff on the cart without disinfecting the cuff or the cart. A review of Resident 28's record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that include diabetes mellitus (high concentration of sugar in the blood), hyperlipidemia (high concentration of fat in the blood), anxiety, and depression. Review of the most recent MDS, for Resident 28 dated 2/04/25, indicated that Resident 28 had no cognitive deficit, with a BIMS score of 13 out of 15. During an observation on 4/16/25 at 8:03 am, LVN 1 took a medication in the manufacturer's box into the room of Resident 28. The medication box was placed on the bedside table without a barrier. The resident then handled the box. After the medication was administered, LVN 1 put the medication box back into the cart drawer with other boxed medications. During an interview with LVN 1 on 4/16/25 at 11:15 am, LVN 1 confirmed that the blood pressure cuff should have been wiped with a disinfectant wipe, the box for the medication should not have been placed on a bedside table, and the resident should not have touched the medication box. LVN 1 stated, (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 04/17/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few I could have transferred whatever one of the resident may have to another resident. This would be an infection control issue. A review of Resident 19's record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that include mild cognitive disorder (the stage between typical thinking skills and dementia), hypertension (pressure in your blood vessels is too high), seizure disorder (when the flow of electrical signals in the brain are disrupted), and psychotic disorder (mental health illnesses that affect the mind where there has been some loss of contact with reality). Review of the most recent MDS for Resident 19 dated 3/14/25, indicated that Resident 19 had no cognitive deficit, with a BIMS score of 15 out of 15. A review of Resident 29's record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that include hypertension (pressure in your blood vessels is too high), and anemia (blood disorder where the blood has a reduced ability to carry oxygen). Review of the most recent MDS for Resident 29 dated 2/07/25, indicated that Resident 29 had no cognitive deficit, with a BIMS score of 15 out of 15. During an observation on 4/16/25 at 8:23 am, LVN 2 took the blood pressure of Resident 19. At 8:55 am LVN 2 used the blood pressure cuff on Resident 29 without disinfecting the blood pressure cuff in-between the two residents. During an observation on 4/16/25 at 8:23 am, LVN 2 took a medication in the manufacturer's box to Resident 19 who was sitting at a table. The medication box was placed on the table without a barrier. The resident then handled the box. After the medication was administered, LVN 2 put the medication box back into the cart drawer with other boxed medications. During an interview with LVN 2 on 4/16/25 at 11:23 am, LVN 2 confirmed that the blood pressure cuff needed to be wiped down between residents with disinfectant wipes, the box for the medication should not have been placed on a table, and the resident should not have touched the medication box. LVN 2 stated, This is because of infection control. During an interview with the Nurse Manager (NM) and Director of Staff Development (DSD) on 4/16/25 at 10:21 am, both confirmed that the blood pressure cuffs should have been wiped down with disinfectant wipes after each resident. They also confirmed that medical equipment, including carts need to be wiped down. The NM confirmed that the medications boxes should not be placed on tables or allow residents to handle the boxes because of infection control issues. Both confirmed and agreed, Re-education of the nurses is due. During an interview with the Infection Prevention Nurse (IP) on 4/16/25 at 11:27 am, IP confirmed that the blood pressure cuffs should have been wiped with disinfectant wipes because that was an infection control issue. IP also confirmed that residents should not be touching medication boxes, and medication boxes should not touch furniture. IP stated this is another infection control issue. IP stated, It looks like some in-services need to be done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555420 If continuation sheet Page 4 of 4