Deficiency Records for Eastern Plumas Hospital- Portola Campus Dp/snf
Updated as of June 01, 2020
This is not the most recent data for Eastern Plumas Hospital- Portola Campus Dp/snf. For the most recent information, click here.
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 the wrongful use of the resident's belongings or money. | Health | 2020-01-29 | 2020-02-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-22 | 2020-02-18 | Y |
| 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-01-21 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-12-26 | 2020-01-21 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-12-14 | 2020-01-21 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-12-14 | 2020-01-21 | Y |
| 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 | 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 ne | 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-05 | 2020-01-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-05 | 2020-01-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-15 | 2019-12-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-11-15 | 2019-12-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-08 | 2019-12-31 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-22 | 2019-12-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-04 | 2019-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-04 | 2019-11-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-03 | 2019-11-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-03 | 2019-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-03 | 2019-11-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-15 | 2019-09-12 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-15 | 2019-09-12 | Y |
| 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 ne | Health | 2019-07-15 | 2019-09-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-24 | 2019-06-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-13 | 2019-05-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-13 | 2019-05-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-13 | 2019-05-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-01 | 2019-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-24 | 2019-03-06 | Y |
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-02 | 2019-01-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-12-06 | 2019-01-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-12-06 | 2019-01-24 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-12-06 | 2019-01-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-06 | 2019-01-24 | Y |
| 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 |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2018-08-31 | 2018-10-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-31 | 2018-10-18 | Y |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2018-08-31 | 2018-10-18 | Y |
| Assess the resident when there is a significant change in condition | Health | 2017-12-22 | 2018-02-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-22 | 2018-02-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-22 | 2018-02-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2017-12-22 | 2018-02-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2017-12-22 | 2018-02-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-22 | 2018-02-13 | 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 | 2017-12-22 | 2018-02-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2017-12-22 | 2018-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-22 | 2018-02-13 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-01-04 | 2018-01-18 | N |
| Use approved construction type or materials. | Fire Safety | 2018-01-04 | 2018-01-18 | 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 | 2018-01-04 | 2018-01-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-04 | 2018-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-04 | 2018-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-04 | 2018-01-18 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-09-14 | 2017-10-17 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-14 | 2017-10-17 | 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 | Not Fixed | N |
