Modoc Medical Center D/P SNF

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their visitation policy and procedure (P&P) for one out of three sampled residents (Resident 1) when Resident 1 was denied (not allowed) visitors of his choosing, the facility did not notify Resident 1 that his friend (Visitor) had been denied visits, there was no documentation present in the medical record, and rules and regulations regarding visitors were not posted for the public and residents to review. This failure violated Resident 1's right to receive visitors of his choosing and had the potential to cause psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to ensure bedframes were maintained for resident safety when the Medical Equipment Management Plan and manufacture recommendations were not followed for one of four sampled residents (Resident 1), when the footboard fell off of Resident 1's bed. This had the potential to subject all residents to injury from equipment that the facility had not regularly inspected and maintained for the safe use by residents.

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when a medication cart was observed to be left unlocked on two occasions. This had the potential to result in unauthorized access to medications that had the potential to cause illness and death.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. This had the potential to spread a communicable disease and cause cross-contamination.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) who was on duty, eight hours out of every day, seven days a week. This failure had the potential for RN assessment skills and supervision to not be available every day for residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to report a COVID-19 (a contagious virus that caused respiratory illness) outbreak which affected four residents (Residents 5, 19, 43, and 45) and four staff members to the California Department of Public Health (CDPH). This failure had the potential to expose further residents to illness, which could have threatened their health and well-being.

Inspectors wroteBased on interview, and record review, the facility's pharmacy consultant failed to identify drug irregularities which included the diagnoses and necessary indications, including target behaviors, for each psychotropic drug (any drug that affects brain activities associated with mental processes and behavior), or antipsychotic drug (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking), and the Centers for Medicare and Medicaid Services (CMS) requirement to limit as needed (PRN) psychotropic medications to 14-days, unless there was a documented rationale which included why the medication needed to be extended past 14-days, and the duration, for three of eight sampled resident records reviewed for unnecessary medications (Residents 3, 37, and 25). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 4 of 8 sampled residents (Residents 3, 8, 25, and 37) who received psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior), or antipsychotic drugs (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking) had adequate diagnoses and clinical indications for use including monitoring of target behaviors to assess effectiveness, monitoring of adverse side effects, and documentation by the physician that included the rationale, and duration for as needed (PRN) psychotropic drugs that exceeded 14-days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that the ice machine dispenser area was free of mineral deposits and debris. This failure had the potential to promote the growth of mold which could have cross contaminated the ice and led to foodborne illness among those residents, staff, and visitors who consumed it, which could lead to negative outcomes.

Inspectors wroteBased on interview, and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to develop and implement a plan of action to correct deficiencies related to unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). As a result of this failure, a pattern of deficiencies was present regarding unnecessary psychotropic medications control that had the potential to harm all residents who received these drugs. (Refer to F 756, and F 758).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and implement all interventions in the care plan including having a sitter, to prevent one of 16 sampled residents (Resident 3), who was a high risk for elopement (leaving the building without permission), from leaving the building. This had the potential to result in a serious injury to Resident 3, which could lead to negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility did not have the required membership at its Quality Assessment and Assurance (QAA) meetings, when the Medical Director missed the meetings for one quarter. This failure had the potential for unidentified resident care issues to occur, as well as a lack of medical oversight, which could lead to negative clinical outcomes.