Modoc Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at Modoc Medical Center D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF727Oct 5, 2023

  Based 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. Findings: Record review of the staffing schedules for the months of August and September 2023 showed there was no RN working on the following dates: 8/5, 8/6, 8/19, and 8/20; 9/2, 9/3, 9/9, 9/10, 9/16, 9/17, 9/23, 9/24, and 9/30. During an interview, on 10/3/23, at 9:18 am, the Administrative Assistant stated they did not have a full-time RN on the weekends during the months of August and September 2023. […]

• No harm, potential for more than minimal, patternF880Oct 5, 2023

  Based 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. Findings: A facility policy, titled, Outbreak Investigation, revised 1/1/12, was reviewed. An outbreak was defined as an excess level of endemic (constantly present in a specific location) disease or statistically (by the numbers) significant increase in endemic level. The time period would have varied according to the infection. […]

• No harm, potential for more than minimal, patternF756Jun 16, 2022

  Based 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 [CONDITION(S)] 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) [CONDITION(S)] 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… […]

• No harm, potential for more than minimal, patternF758Jun 16, 2022

  Based on interview, and record review, the facility failed to ensure 4 of 8 sampled residents (Residents 3, 8, 25, and 37) who received [CONDITION(S)] 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) [CONDITION(S)] drugs that exceeded 14-days. […]

• No harm, potential for more than minimal, patternF812Jun 16, 2022

  Based 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. Findings: The facility's policy titled, Food Safety: Ice, revised 11/1/21, was reviewed, and indicated that the facility's ice supply would remain free of all possible contaminants. […]