Eastern Plumas Hospital- Portola Campus Dp/Snf

In the surveyor’s words

From the most serious findings on record at Eastern Plumas Hospital- Portola Campus Dp/Snf, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 24, 2025

  Based 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. […]

• Actual harm, isolatedF689May 14, 2025

  Based 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. […]

• Actual harm, isolatedF697May 14, 2025

  Based 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. […]

• Actual harm, isolatedF686Mar 20, 2025

  Based 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. […]

• Actual harm, isolatedF689Feb 7, 2023

  Based on observation, interview, and record review, the facility failed to prevent accidents for one of three sampled residents (Resident 3) when the resident's lower legs were not secured to a mechanical lift (a device used to lift and transfer residents) and the resident began to slip off the lift. Staff lowered the lift to the floor which caused Resident 3 to suffer broken bones in both legs. Findings: Review of Resident 3's admission record indicated she was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought, and mood), dementia (a mental disorder that caused memory loss and confusion), and generalized muscle weakness. […]