Deficiency Records for Eastern Plumas Hospital- Portola Campus Dp/snf
Updated as of March 01, 2024
A list of the most recent deficiencies for Eastern Plumas Hospital- Portola Campus Dp/snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-16 | 2023-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-04-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-28 | 2022-12-21 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-28 | 2022-12-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-19 | 2022-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-06-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-25 | 2022-06-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-25 | 2022-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-25 | 2022-06-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-10 | 2022-02-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-10 | 2022-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-10 | 2022-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-06 | 2021-05-17 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-12-14 | 2020-01-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-14 | 2020-01-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-12-14 | 2020-01-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-12-14 | 2020-01-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-12-14 | 2020-01-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-12-14 | 2020-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-14 | 2020-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-14 | 2020-01-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-14 | 2020-01-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-14 | 2020-01-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-14 | 2020-01-21 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-12-14 | 2020-01-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-14 | 2020-01-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-12-14 | 2020-01-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-14 | 2020-01-21 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-12-14 | 2020-01-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-12-14 | 2020-01-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-12-14 | 2020-01-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-14 | 2020-01-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-12-14 | 2020-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-14 | 2020-01-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-23 | 2019-02-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-11-20 | 2018-12-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-11-20 | 2018-12-18 | N |
| 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. | Health | 2018-11-20 | 2018-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-20 | 2018-12-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-20 | 2018-12-18 | N |
