Eastern Plumas Hospital- Portola Campus Dp/SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were protected from accidents and hazards when: One of two residents sampled for falls with injuries (Resident 9), was transferred by staff from her bed to her wheelchair, without using the proper equipment. Two of three shower rooms were observed to have unlocked, open cabinets that contained disposable razors and a sharps container (a plastic safety container for needles and sharp objects), that was over spilling with used razors. These failures resulted in Resident 9 sustaining a broken ankle and had the potential for residents who used the shower rooms to be injured by cuts from razors which could negatively impact residents physical and emotional well-being. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, homelike environment when three of three shower rooms were found to be less than adequately maintained when paint was chipping from walls and ceiling, door jambs were missing paint with hints of rust, shampoo, and/or other products had spilled and dried in an open cupboard with clean towels placed on top, bolts, screws, and nuts that adhere the tub and toilet to the floor were rusty, the foot of the tub and around the toilet was unclean, and hard bristle brushes to scrub the floor were left hanging on hand rails in the shower. This failure had the potential to result in disease transmission, with increasing health and overall wellbeing concerns to those residents utilizing the common space. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to protect four of four sampled residents (Resident 3, 16, 20, and 45) from abuse by chemical restraints when Haldol (an antipsychotic medication used to alter mood and behavior) intramuscularly (IM, a shot) was used in excessive doses, without adequate indications for use, and without trying non-pharmacological interventions (redirection without using medication) first. This subjected the residents to potentially harmful and irreversible unwanted adverse side effects from antipsychotic use and violated their rights for alternative treatment methods prior to the use of medication. This had the potential to seriously impair their ability to attain or maintain their highest practicable level of physical, emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary, clean kitchen equipment when the ice machine acquired a large amount of mineral buildup (white coating that harbors bacteria) on the tray and the spout, debris was noted in the internal cabinet area of the machine, and the cupboard the ice machine sat upon did not appear clean. This failure had the potential to result in ice that was contaminated with bacteria which could negatively impact the health and overall well-being to residents, staff and visitors. During a review of the facility's policy and procedure titled, Cleaning and Sanitizing Ice Machines, dated revised 9/2024, the policy indicated, It is the policy of [the facility name] that all ice machines will be properly maintained and cleaned. They should be clean to the sight and touch.including ice machine tray and spout. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control standards for 2 out of 5 sampled residents during a medication pass and dining (Resident's 1 and 23) when: 1. Staff did not sanitize a potentially contaminated instrument used to puncture and remove a safety seal on a medication.2. A medication container was brought into a resident's room and placed on a potentially contaminated surface without a barrier.3. Staff did not sanitize their hands after touching potentially contaminated surfaces while feeding residents in the dining room. This had the potential to spread a communicable disease and cause cross-contamination. 1. [...]

Inspectors wroteBased on observation, interview, and record review, this requirement was not met when staff were inadequately trained in resident care for two of two sampled residents (Resident 9 and 36) when:1. Certified Nursing Assistant (CNA) failed to follow policy and the resident's care plan when transferring Resident 9 from bed, which resulted in Resident 9 sustaining a broken right ankle.2. A Registered Nurse (RN), delegated her responsibility to a CNA to administer oxygen to Resident 36. 1. Resident 9 was admitted to the facility for heart disease with heart failure, lymphoma (a form of blood cancer), a history of falling, cervicalgia (back pain), osteoporosis, and an amputated (surgically removed) left leg. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when staff failed to follow a physician ordered therapeutic diet and fortify (add extra calories) one of six sampled residents who were on therapeutic diets. (Resident 12)This had the potential to cause undesired weight loss, delayed wound healing and malnutrition for Resident 1 and other residents who had physician ordered fortified diets. A review of the facility's record titled, Policy and Procedures Manual: High Calorie/High Protein Supplements, Nutrition Interventions dated 2021 indicated, Individuals needing supplemental nutrition will be served a suitable high calorie/high protein diet, and Nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Resident 1) sampled for falls was free from an avoidable fall. According to the facility's assessments, Resident 1 had difficulty maintaining an upright posture and poor safety awareness. Certified Nursing Assistant (CNA) B observed Resident 1 leaning over and reaching for the floor but did not help Resident 1 to a safe position and left Resident 1 unsupervised. Resident 1 had no post fall assessment and Resident 1's care plan did not provide interventions for what to do if Resident 1 was found on the floor unwitnessed. This fall resulted in Resident 1 falling and sustaining a broken left hip. Resident 1 required hospital admission for surgery. Resident 1 had a decline in her physical, social, and mental well-being due to increased pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) sampled for post-fall pain received the treatment and care to manage pain when: * Staff did not promptly assess Resident 1 for a change of condition for a new onset of pain in her left arm and left hip after she was found on the floor. Staff picked Resident 1 up off the ground and put her into a chair while she complained of pain. * Staff gave Resident 1 medication ordered for mild pain when she experienced moderate pain. * The Physician (MD) was not immediately notified of Resident 1's fall and complaint of pain with movement. These failures caused Resident 1 to experience moderate and severe left arm and left leg pain for eight hours, prevented her from eating lunch or dinner. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly identify and notify the physician and responsible party of a change of condition for one of two residents (Resident 1) when Resident 1 had a fall which resulted in a new onset of pain. This resulted in an eight-hour delay in treatment for Resident 1 which caused unnecessary pain and suffering.

Inspectors wroteBased on Interview and Record Review, the facility failed to meet this requirement when a staff member spoke to a resident (Resident 1) in a manner the resident perceived as disrespectful. This had the potential to result in psychological harm to Resident 1 and compromised the resident's sense of well-being and feeling of being in a home-like environment. Resident 1 was admitted to the facility for conditions including age-related debility (unable to perform tasks that are part of daily living), arthritis, and heart disease. A review of the facility's policy titled, Elder or Dependent Adult Abuse Reporting indicated that each resident shall be treated as an individual with dignity and respect and shall not be subject to abuse of any kind. The policy further defined abuse as including verbal abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on an identified pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence, where bones are close to the surface of the skin), to evaluate, and intervene in a timely manner to prevent an avoidable pressure ulcer for one of three residents (Resident 1) sampled for pressure ulcers. This resulted in Resident 1 developing a 1-centimeter (cm) x 1.25 cm pressure ulcer on her left heel.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS, a standardized resident assessment) accurately reflected the status of two of three sampled residents (Resident 1 and 3) when the skin assessments did not accurately reflect their skin status. This failure had the potential for staff to not be fully informed of the residents ' health status to determine the need for further assessment and care interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident ' s needs and choices for personal hygiene - oral care were met for two of three sampled residents (Resident 1 and 2) when, · Yellow thickened substance on the surface of the tongue of Resident 1 and 2. · Resident 1 was observed to have the food from the day before stuck in between her teeth and on her tongue. · Resident 2 was observed to have blue cake that she ate the night before smearing around her mouth. This deficient practice had the potential to adversely affect the resident's psychosocial well-being by not receiving hygiene and feeling dirty.

Inspectors wroteBased on interview and record review, the facility ' s nursing staff failed to update and maintain the facilities Antibiotic Steward Program. (Log used to identify, track, and monitor infections and antibiotic use for the residents.) This failure had the potential to result in an inadequate antibiotic stewardship program to identify potential inappropriate antibiotic use and antibiotic resistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1). Maintain the Ice/Water Dispensing machine per manufacturer recommendations allowing a buildup of moist, black residue to collect on the water supply nozzle and; 2). Maintain a functioning drain for the dishwashing machine allowing water to spill out of the drain and onto the floor. These failures had the potential to negatively impact resident health.

Inspectors wroteBased on interview and record review the facility failed to protect Resident 1 (R1) from abuse when a facility Housekeeper (HK1) took R1's jewelry, posed for pictures wearing R1's jewelry then pawned R1's jewelry. This failure created anxiety and stress for Resident 1 which could lead to adverse clinical outcomes.

Inspectors wroteBased on observation and interview, the facility failed to maintain handrails in the corridors for a 10.5 month period, from June 6, 2023 until April 25, 2024.

Inspectors wroteBased on observation, interview and record review the facility did not ensure safe food handling practices when the cook was observed without wearing a full hair covering while serving lunch meals. This failure had the potential to cause contamination of food leading to residents contracting foodborne illness and undesirable clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to make sure that staff wore appropriate Personal Protective Equipment (PPE--which included gloves and gowns) when entering the rooms of 14 residents (Residents 4,6,7,9,13,15,20,21,27,28,30,34,38 and 42) who were COVID-19 (a respiratory disease caused by SARS-CoV-2, a coronavirus discovered in 2019) exposed, but not infected, after having been in rooms with COVID-19 positive (infected) residents. This failure had the potential to further expose the residents who had tested negative to a risk of infection from COVID-19, which could have led to serious illness.