F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
Based on interview and record review the facility failed to ensure there was a Licensed Nurse (LN) in the
facility to provide care for 14 out of 14 residents when LN A left the facility for a lunch break. This had the
potential to impact resident health status and could have caused a decline in psychosocial well-being.
Findings:A review of the Facility Assessment Tool, dated 11/10/25, indicated the facility would staff two LNs
on the night shift.A review of the undated Staffing Ratio for Revamping [changing or redoing] up Staffing,
indicated, when the facility census (how many residents were in the facility) was less than 30, there would
be one LN working the night shift.During an interview on 1/13/26 at 12:19 pm, Certified Nurse Assistant
(CNA) B stated, one night, LN A went outside for a smoke break, and she drove away and was gone for an
hour. CNA B confirmed, there was no LN in the facility or on the facility grounds while LN A was gone and
stated, it was me and another CNA. CNA B stated a resident that was awake [Resident 1] was upset that
the nurse left the facility.During an interview on 1/13/26 at 1:12 pm, Resident 1 confirmed, LN A had left the
facility one night and stated, the nurse said she was going on break and didn't come back for a long time,
maybe an hour. We waited a long time for her to come back and we notified [the Nurse Manager,
NM].During an interview on 1/13/26 at 2:25 pm, NM confirmed, CNA B had called NM in the evening on
12/5/25 due to LN A leaving the facility.During a concurrent interview and record review on 1/13/26 at 2:25
pm, with Director of Nursing (DON), security camera video footage, dated 12/5/25 was reviewed. DON
indicated that the review of the security camera footage showed LN A sitting in their car for approximately
15 minutes prior to leaving the facility grounds. DON stated, LN A was out of the building for approximately
one hour. DON confirmed that LN A had driven away from the facility approximately 11:10 pm or 11:15 pm
and returned approximately 40 to 45 minutes later. DON confirmed, there was no LN in the facility for the
time LN A was gone.During an interview on 1/13/26 at 4:33 pm, LN A stated, I left to go get food. LN A
confirmed that LN A was the only LN working on the evening of 12/5/25 and stated, a few times [in the
past], a nurse just showed up to give me a lunch break, and I'm use to just leaving. I didn't think about
being the only nurse. I'm used to having another nurse there. I didn't think, I guess I didn't realize at the
time, reporting off [providing resident specific details about their care to another LN] to the CNAs left the
facility without a nurse.
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
01/14/2026
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on interview and record review the facility failed to ensure that medication was stored securely when
Licensed Nurse (LN) A left the medication keys at the nurse's station during a lunch break. This failure
caused medication to be accessible to facility staff and residents and had the potential to cause a decline in
resident health status. A review of the facility's policy and procedure (P&P) titled, Medication Cart, revised
8/1/24, indicated, the Pharmacists and LN would have access to the medication cart. The P&P indicated, If
a nurse leaves the floor for any reason, they must turn over the keys to the cart to another nurse. During an
interview on 1/14/26 at 11:41 am, Nurse Manager (NM) stated, I heard she [LN A] left one night for her
lunch break and threw her medication keys on the counter at the nurse's station. One of the Certified Nurse
Assistant's (CNA) called me. During an interview on 1/14/26 at 12:19 pm, CNA B confirmed that LN A had
left the facility for a lunch break and left the medication keys unsecured at the nurse's station and Resident
1 had witnessed it. CNA B stated, Resident 1 was awake and knew the nurse left. During an interview on
1/14/26 at 1:12 pm, Resident 1 confirmed being present when LN A placed the medication keys at the
nurses' stations and left the facility for a lunch break. Resident 1 stated, She left her med keys, I think, at
the nurses station. During an interview on 1/14/26 at 2:24 pm, Director of Nursing (DON) confirmed, when
the LN left the facility for a lunch break, they would hand over their medication keys to another LN. DON
confirmed, on 12/5/25, LN A left the facility for a lunch break, placed the medication keys at the nurse's
station, and the keys were available for anyone to use. During an interview on 1/14/26 at 4:33 pm, LN A
confirmed leaving the medication keys in an unlocked area and LN A stated, I left to get food. I told the
CNAs I was going to lunch, and put my keys in a drawer at the nurse's station. LN A confirmed that two
CNAs and Resident 1 were present at the time LN A placed the medication keys in the unlocked drawer at
the nurse's station.
Event ID:
Facility ID:
555420
If continuation sheet
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