Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastern Plumas Hospital- Portola Campus Dp/snf during CMS and state inspections, most recent first.
A resident with multiple health conditions and an amputation was injured when a CNA transferred her without the required slide board and second staff member, contrary to her care plan and posted instructions, resulting in a fractured ankle. Additionally, two shower rooms were found with unlocked cabinets containing new razors and an overfilled sharps container with used razors accessible to residents, posing further safety risks. Staff confirmed these practices did not meet safety standards.
Surveyors observed that three shower rooms were inadequately maintained, with chipping paint, rust, unclean areas around tubs and toilets, and improper storage of cleaning equipment and used razors. Staff, including a CNA, a licensed nurse, the ADON, and the DON, confirmed that the rooms were not clean or maintained to acceptable standards, in violation of facility policy requiring cleaning and disinfection between uses.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
Surveyors found that the ice machine and the cupboard it sat upon were not maintained in a sanitary condition, with significant mineral buildup, debris, and unclean surfaces observed. Maintenance staff and the Director of Plant Management confirmed the presence of buildup and debris, indicating a failure to follow the facility's cleaning policy for kitchen equipment.
Staff did not adhere to infection control protocols during medication administration and feeding. A nurse used a writing pen to open a medication bottle, and another brought a medication box into a resident's room, placing it on a surface without a barrier. Additionally, a CNA assisted two residents with eating and touched various potentially contaminated surfaces without performing hand hygiene between tasks. These actions were confirmed by staff and leadership as breaches of infection control policy.
Nurses and nurse aides lacked the appropriate competencies to care for every resident in a way that maximizes each resident's well-being, resulting in care that did not support residents' highest level of physical, mental, and psychosocial well-being.
Staff did not follow a physician-ordered fortified diet for a resident, as the intended fortification (an extra pat of margarine) was not incorporated into the meal and was not offered to the resident by CNAs, who were unaware of its purpose. The DON confirmed staff were not trained on this requirement, and the RD expected fortification to be part of the recipe, not served separately.
A resident with severe cognitive impairment and high fall risk was left unsupervised after being observed in an unsafe position. Staff failed to assist the resident to safety, did not perform a post-fall assessment, and delayed notifying the physician after the resident was found on the floor in pain. The resident sustained a fractured hip, required hospitalization and surgery, and experienced significant pain and decline.
A resident with severe cognitive impairment and multiple health conditions experienced a fall and reported pain in her left arm and hip. Staff did not promptly assess her condition, failed to notify the physician in a timely manner, and administered acetaminophen ordered only for mild pain despite the resident experiencing moderate to severe pain. The resident remained in pain for several hours, did not eat, and was later found to have a fractured hip. Facility policies for post-fall assessment and pain management were not followed.
A resident with multiple comorbidities experienced a fall resulting in significant pain, but staff failed to promptly notify the physician and responsible party as required by facility policy. The LPN delayed notification for several hours, and documentation of required notifications was incomplete. The resident was later found to have a left hip fracture, and the delay led to unnecessary pain and suffering.
A resident in an LTC facility, admitted with age-related debility and other conditions, experienced a disrespectful interaction with the DON, who responded to a light-hearted comment by saying, 'I could let you sit in a wet diaper.' This was perceived as disrespectful, especially given the resident's history of conflicts with the DON. The facility's policy emphasizes treating residents with dignity, and the incident was corroborated by the ADON and a community advocate.
A resident with Alzheimer's and dementia developed a pressure ulcer on her left heel due to the facility's failure to provide timely and appropriate care. Despite identifying the ulcer, there was a 47-day delay in notifying the physician and obtaining a wound care order. Inadequate documentation and communication, along with the absence of a formal wound care policy, contributed to the deficiency.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential care gaps. One resident, with Alzheimer's and dementia, was inaccurately marked as not at risk for pressure ulcers, missing a prevention care plan. Another resident, with quadriplegia and existing pressure ulcers, was not documented correctly in the MDS, despite ongoing treatment. These inaccuracies could lead to uninformed staff and inadequate care interventions.
Two residents with Alzheimer's and dementia were not provided adequate oral hygiene care, resulting in visible hygiene issues such as food residue and buildup on their teeth and tongues. Despite requiring maximal assistance, one resident missed oral care for 22 shifts, while the other had no intervention plan for care refusal. Staff interviews revealed systemic neglect, particularly during night shifts, and missing records confirmed the lack of consistent care.
The facility's nursing staff failed to maintain the Antibiotic Stewardship Program, resulting in missing and incomplete documentation for several residents. This included essential information such as dates, medical record numbers, and antibiotic details, hindering the facility's ability to monitor and minimize antimicrobial resistance. The Infection Preventionist and DON confirmed the deficiencies, which compromised the facility's infection control efforts.
The facility failed to maintain the Ice/Water Dispensing machine and the dishwashing machine's drain, leading to potential health risks. The Ice/Water machine had a buildup of black residue on the nozzle, and the dishwashing machine's drain overflowed due to a clog. The issues were not reported or addressed in a timely manner, impacting resident health.
A resident's jewelry was taken by a housekeeper who wore and pawned it, causing distress to the resident. The resident, with decreased mental functioning, had placed the jewelry in a cup before an X-ray procedure. The facility staff, including the ADON and DON, investigated after the resident's daughter reported the missing items. A Restorative Nurses Aid discovered photos online of the housekeeper wearing the jewelry, leading to the housekeeper's admission and the eventual return of the items.
The facility did not maintain handrails in the corridors for 10.5 months due to a renovation project. During a survey, it was noted that sections of the corridors lacked handrails. The Director of Plant Operations confirmed the removal of handrails for renovations and was unaware of the regulatory requirement for their presence.
Failure to Prevent Accidents and Secure Hazards
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents. One resident with significant medical conditions, including heart disease, lymphoma, a history of falls, osteoporosis, and an above-the-knee amputation, was transferred from her bed to a wheelchair by a CNA without the use of the required slide board and without a second staff member assisting. The resident's care plan, posted instructions, and therapy documentation all specified that a slide board and two-person assist were necessary for safe transfers. Despite this, the CNA attempted a stand-and-pivot transfer, which the resident could not safely perform due to her single leg and pain, resulting in a fall and a fractured ankle that required emergency room treatment. Additionally, the facility did not ensure the safety of shower rooms, as two out of three rooms were observed to have unlocked and open cabinets containing new disposable razors and an overfilled sharps container with used razors protruding from the opening. These items were easily accessible to residents, creating a risk of injury. Multiple staff, including a licensed nurse, the assistant director of nursing, and the director of nursing, confirmed that razors and sharps should not be left accessible in this manner. The facility's own policies and standard procedures, as well as external guidelines referenced by staff, required the use of proper equipment and secure storage of hazardous items to ensure resident safety. The observed failures directly resulted in a resident injury and created the potential for further harm to other residents.
Failure to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in three of three resident shower rooms, as evidenced by multiple observations of inadequate maintenance and cleanliness. Surveyors found paint chipping from walls and ceilings, missing paint and rust on door jambs, and rust on bolts, screws, and nuts securing tubs and toilets to the floor. In one shower room, a dry, flaky substance, possibly shampoo, was found spilled and dried on the bottom shelf of an open cupboard, with clean towels stacked on top. The foot of the bathtub and the area around the toilet were also unclean. Used razors were observed protruding from an almost full sharps container, and used hard bristle brushes intended for floor cleaning were left hanging on shower safety handrails in multiple rooms. Staff interviews confirmed the observations, with a CNA stating that the hard bristle brush should not be left on the handrails where residents could come into contact with it, and that the rooms were not maintained to acceptable standards. Both a licensed nurse and the assistant director of nursing acknowledged that the shower rooms were not adequately maintained or clean. The director of nursing also confirmed these findings upon review of the rooms and photographic evidence. The facility's own policy required cleaning and disinfecting of shared equipment and areas between each use, which was not adhered to in these instances.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Unsanitary Ice Machine and Surrounding Area
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions for kitchen equipment, specifically the ice machine. The ice machine was found to have a significant amount of mineral buildup on the tray and inside the ice spout, as well as debris in the internal cabinet area. Additionally, the cupboard supporting the ice machine was unclean, with visible buildup, water, splash marks, and debris. These findings were confirmed during multiple observations and interviews with maintenance staff and the Director of Plant Management, who acknowledged the presence of buildup and debris and agreed that the machine and surrounding area appeared unclean. A review of the facility's policy on cleaning and sanitizing ice machines indicated that all ice machines should be properly maintained and cleaned, including the tray and spout, and that exterior scaling should be removed as needed. Despite this policy, the observed conditions did not meet these standards, as the ice machine and its surrounding area were not clean to sight or touch. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Failure to Follow Infection Control Standards During Medication Administration and Resident Feeding
Penalty
Summary
Staff failed to follow infection control standards during medication administration and resident feeding, as observed and confirmed through interviews and record reviews. In one instance, a nurse was unable to remove a safety seal from a new liquid medication and used a writing pen to puncture and scrape the inside edge of the bottle opening. The nurse later acknowledged that this was inappropriate and could cause an infection control issue. The facility's policy on standard precautions requires measures to reduce the risk of infection transmission, but this was not followed in this case. In another event, a nurse brought a medication in its manufacturer’s box into a resident’s room and placed it directly on the bedside table without a barrier. After administering the medication, the nurse returned the medication to the box and placed it back in the medication cart with other boxed medications. The nurse confirmed that the medication box is porous and cannot be thoroughly cleaned, identifying this as an infection control issue. Facility leadership, including the Assistant Director of Nursing and Director of Nursing, confirmed that these actions were not in line with infection control expectations. Additionally, a certified nursing assistant was observed assisting two residents with eating in the dining room and touching potentially contaminated surfaces such as wheelchair handles, chairs, other residents’ trays, and countertops without performing hand hygiene between these actions. The assistant admitted to not considering the need for hand sanitizing after touching these surfaces. Facility policy requires hand hygiene after touching patient surroundings and before feeding, but this was not adhered to during the observed meal service.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in residents not receiving care in a manner that supports their highest level of physical, mental, and psychosocial well-being.
Failure to Follow Physician-Ordered Fortified Diet for Resident
Penalty
Summary
Staff failed to follow a physician-ordered therapeutic fortified diet for one of six sampled residents on such diets. Specifically, the dietary manager was observed plating food for a resident requiring a fortified diet but did not add any fortification to the main entrée, instead placing an extra pat of margarine on the tray. The margarine, intended as the fortification, was not incorporated into the food but left on the tray alongside the napkin. When the tray was presented to the resident, the certified nursing assistant did not offer the margarine and was unaware it was part of the fortified diet order. Another CNA also did not know that the butter pat was intended as fortification, stating that residents could eat whatever they wanted. The Director of Nursing confirmed that nursing staff were not aware of the role of the butter pat in the therapeutic diet and had not received training to ensure its use for residents requiring fortified diets. The registered dietitian stated that her expectation was for additional calories to be incorporated into the recipes, not simply presented as margarine pats on the tray. Facility policy required that individuals needing supplemental nutrition be served a suitable high calorie/high protein diet, with nursing staff supervising delivery and consumption of supplements and recording this in the medical record. These steps were not followed for the resident in question.
Failure to Prevent and Respond to Resident Fall Results in Serious Injury
Penalty
Summary
A resident with a history of dementia, Parkinsonism, osteoporosis, traumatic brain injury, and severe cognitive impairment was identified as high risk for falls, with documented balance problems and poor safety awareness. Despite these risks, the resident was left unsupervised after being observed by a CNA leaning over and reaching for the floor while seated. The CNA did not assist the resident to a safe position or ensure her safety before leaving, and subsequently, the resident was found on the floor by a housekeeper, with no staff present in the hallway or at the nurse's station. After the fall, staff failed to perform a post-fall assessment or take vital signs, and the resident's care plan did not include specific interventions for unwitnessed falls. The nurse and CNA lifted the resident from the floor without assessing for injury, despite the resident expressing pain and being unable to bear weight. The nurse did not notify the physician or the resident's responsible party at the time of the incident and delayed communication until the end of the shift. The Director of Nursing later acknowledged that the facility's post-fall policy was not followed and that the incident should have been treated as a fall, regardless of the care plan's note about the resident sitting on the floor. As a result of the fall, the resident sustained a displaced left hip fracture, requiring hospital admission and surgery. Following the injury, the resident experienced significant pain, a decline in physical, social, and mental well-being, and became completely dependent on staff for assistance. The failure to provide adequate supervision, timely assessment, and appropriate post-fall interventions directly contributed to the severity of the resident's injury and subsequent decline.
Failure to Provide Timely Assessment and Appropriate Pain Management After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including dementia, parkinsonism, osteoporosis, and a history of traumatic brain injury, experienced a fall in the facility. Staff failed to promptly assess the resident for a change in condition after the fall, despite the resident expressing pain in her left arm and hip. Instead of conducting an immediate assessment as required by facility policy, staff lifted the resident from the floor and placed her in a chair while she complained of pain. No vital signs or neurological assessments were performed at the time, and the physician was not notified immediately of the incident or the resident's complaints of pain. Following the fall, the resident continued to express moderate to severe pain, was unable to bear weight, and refused food. Staff administered acetaminophen, which was only ordered for mild pain, despite the resident reporting moderate pain levels. The medication was ineffective, and the resident's pain persisted for several hours. Documentation shows that the resident did not eat lunch or dinner due to her pain, and her pain was not adequately reassessed or managed according to the facility's pain management policy. The physician was not notified of the resident's ongoing pain and change in condition until several hours after the incident, and only after the pain had escalated to severe levels. Interviews with staff and witnesses confirmed that the resident was in visible distress, repeatedly vocalized her pain, and was unable to participate in normal activities. The lack of timely assessment, inadequate pain management, and delayed physician notification resulted in the resident experiencing prolonged pain and discomfort. The facility's own policies regarding post-fall assessment, pain management, and change in condition notification were not followed, directly contributing to the deficiency identified in the report.
Failure to Promptly Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly identify and notify the physician and responsible party of a change in condition for a resident who experienced a fall resulting in new onset pain. According to the facility's policy, any accident involving a resident that results in injury requiring provider intervention, or a significant change in the resident's physical, mental, or psychosocial status, requires immediate assessment and notification of the primary provider, resident representative, and the resident. In this case, the resident, who had a history of dementia, parkinsonism, hearing loss, osteoporosis, and traumatic brain injury, fell from her chair and landed on her left side. Staff observed the resident in pain, crying, and expressing discomfort during and after being assisted back into her chair and later transferred to bed. Despite clear signs of pain and distress, the licensed nurse on duty did not notify the primary physician or the resident's responsible party at the time of the incident. Instead, the nurse waited until the end of her shift to send an email to the medical director, resulting in an eight-hour delay before the physician was made aware of the situation. The physician reported that the initial notification lacked critical details, such as the time of the incident and a proper assessment, and was not informed that the resident had fallen or was experiencing pain with movement. The responsible party was also not notified until later in the evening, just before the resident was sent to the emergency department. Documentation review revealed that required notifications to the physician and family were not completed or documented as done on the facility's alert charting forms. The director of nursing confirmed that there was no documentation of timely notification to the primary physician or responsible party following the change in the resident's condition. The delay in notification and treatment resulted in the resident experiencing unnecessary pain and suffering, and subsequent evaluation in the emergency department revealed an acute displaced subcapital left femoral neck fracture.
Resident's Right to Dignity Compromised by Disrespectful Staff Interaction
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination when a staff member, specifically the Director of Nursing (DON A), spoke to a resident in a manner perceived as disrespectful. The incident involved Resident 1, who was admitted to the facility with conditions such as age-related debility, arthritis, and heart disease, and required substantial assistance for daily activities. During an interaction on or around February 27, 2025, Resident 1, who is cognitively intact, made a light-hearted comment to DON A and LVN B, referring to them as 'Wonder Woman and Hercules.' In response, DON A remarked, 'I could let you sit in a wet diaper,' which Resident 1 interpreted as disrespectful, especially given their history of conflicts. The facility's policy on elder abuse reporting emphasizes treating residents with dignity and respect, explicitly defining verbal abuse as a form of abuse. Interviews with the Assistant Director of Nursing (ADON B) and a volunteer community advocate (ADV C) corroborated the resident's account of the incident. ADON B acknowledged that such a statement would be disrespectful and contrary to the facility's policy, while ADV C confirmed the ongoing tension between Resident 1 and DON A, noting that Resident 1 is a reliable source of information. The incident highlights a failure to maintain a respectful and home-like environment for the resident, as required by the facility's policies.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate care for a pressure ulcer that developed on a resident's left heel. The resident, who was admitted with Alzheimer's disease and dementia, was initially assessed as not having any pressure ulcers. However, a pressure ulcer was later identified by a licensed nurse, who noted a black, dry blister on the resident's heel. Despite this observation, there was a significant delay in notifying the physician and obtaining a wound care order, which occurred 47 days after the initial identification of the ulcer. The facility's documentation and communication practices were inadequate, contributing to the deficiency. The Director of Nursing and other staff members confirmed that there was no consistent documentation of the wound's condition, such as its stage, size, or any discharge. The facility lacked a specific policy for skin assessment, wound care, or pressure ulcer management, and staff relied on online resources instead of formal training. Additionally, the resident's care plan included interventions like floating the heels and using booties, but there was no evidence that these measures were consistently implemented. The facility's failure to accurately assess the resident's risk for pressure ulcers and to document and communicate the wound's condition led to a lack of timely intervention. The resident's medical records showed discrepancies, such as being marked as not at risk for pressure ulcers despite a Braden Scale score indicating otherwise. The lack of a coordinated approach to wound care and the absence of a wound care nurse or formal training further exacerbated the situation, resulting in the development and progression of the pressure ulcer.
Inaccurate MDS Assessments for Skin Conditions
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the skin status of two residents, leading to potential gaps in care. Resident 1 was admitted with a history of Alzheimer's disease and dementia and was assessed with a Braden Scale score indicating a risk for pressure ulcers. However, the MDS completed by a retired RN inaccurately marked Resident 1 as not at risk for pressure ulcers, resulting in the absence of a pressure ulcer prevention care plan. Resident 3, diagnosed with quadriplegia and existing pressure ulcers on the buttocks, was also inaccurately assessed in the MDS. The MDS, completed by the same retired RN, failed to document the presence of pressure ulcers, despite the resident being under treatment for these conditions since a previous diagnosis. This discrepancy was confirmed during a review with the Director of Nursing (DON). These inaccuracies in the MDS assessments for both residents could lead to staff being uninformed about the residents' true health status, potentially affecting the care interventions required. The facility's policy and the CMS guidelines emphasize the importance of accurate MDS assessments to ensure appropriate care planning, which was not adhered to in these cases.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for two residents, leading to visible hygiene issues. Resident 1, who has severe cognitive impairment due to Alzheimer's disease and dementia, was observed with food from the previous day stuck between her teeth and on her tongue, along with a yellowish buildup on her tongue. Her family member reported never witnessing staff provide personal hygiene care during visits. Resident 1's medical records indicated she required maximal assistance for oral hygiene, yet there were 22 shifts where she did not receive oral care. Resident 2, also diagnosed with Alzheimer's disease and dementia, was observed with a thick yellowish substance on her tongue and blue cake residue around her mouth from the previous night. Despite having a care plan that aimed to keep her clean and well-groomed, there was no intervention plan for when she refused oral care. During an interview, Resident 2 expressed difficulty accessing water and locating the call light, indicating a lack of assistance in meeting her basic needs. Interviews with staff revealed systemic issues in providing oral care, with CNAs acknowledging that oral hygiene was often neglected, especially during night shifts. The Director of Nursing confirmed the absence of an ADL policy and acknowledged missing records for oral care. The facility's job postings outlined expectations for CNAs to provide oral hygiene, yet these duties were not consistently fulfilled, as evidenced by the observations and staff admissions.
Incomplete Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility's nursing staff failed to update and maintain the Antibiotic Stewardship Program (ASP), which is crucial for identifying, tracking, and monitoring infections and antibiotic use among residents. This deficiency was identified through interviews and record reviews, revealing that the ASP log was missing or incomplete for several residents. Specifically, the log lacked essential information such as dates, medical record numbers, dose and duration of antibiotics, start and stop dates, clinical indications, and diagnosis. The absence of this information hindered the facility's ability to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance. The review of medical records for multiple residents indicated that urinalysis tests were ordered, and culture and sensitivity results showed positive findings for various bacteria, including Escherichia coli and Staphylococcus aureus. However, the ASP log failed to document critical details such as the date of culture and the date and initials of nurses who faxed information to the pharmacy. This lack of documentation was confirmed by the Infection Preventionist and the Director of Nursing, who acknowledged that the ASP log was incomplete and needed to be updated to ensure the safe and appropriate use of antimicrobial agents. The facility's policies and procedures outlined the responsibilities of the Infection Preventionist and the Antimicrobial Stewardship Committee in monitoring and managing infections and antibiotic use. Despite these guidelines, the facility did not adhere to its own policies, resulting in missing and incomplete data in the ASP log. This failure compromised the facility's ability to effectively track antibiotic use and resistance trends, potentially leading to inappropriate antibiotic use and increased risk of antimicrobial resistance among residents.
Failure to Maintain Equipment Leads to Health Risks
Penalty
Summary
The facility failed to maintain the Ice/Water Dispensing machine according to the manufacturer's recommendations, resulting in a buildup of moist, black residue on the water supply nozzle. This issue was identified during an observation in the resident's kitchenette, where a white paper towel was used to wipe the nozzle, revealing the residue. The Biomed staff confirmed that the nozzle should have been clean and acknowledged that the machine was last cleaned by an outside contractor on 2/1/24, as per the manufacturer's guidelines. However, the service manual indicated that more frequent maintenance might be necessary. The Activities Director confirmed that residents obtained drinking water from this machine. Additionally, the facility did not maintain a functioning drain for the dishwashing machine, leading to water spilling onto the floor. During an observation in the kitchen, the Dietary Aide demonstrated that the dishwasher's drain required a stop-and-go method to prevent overflow. The Dietary Manager confirmed the ongoing issue with the drain and admitted to not reporting the problem to the Maintenance Director, who later identified a clogged drain as the cause of the overflow. The Maintenance Director noted that a similar issue had been repaired approximately six months prior, but was not informed of the current problem.
Housekeeper Takes and Pawns Resident's Jewelry
Penalty
Summary
The facility failed to protect a resident from abuse when a housekeeper took the resident's jewelry, wore it, and then pawned it. The resident, who was admitted with diagnoses including heart failure and a history of falling, required assistance for daily needs and was alert but had decreased mental functioning, scoring 8 out of 15 on the BIMS Test. The incident occurred when the resident placed her two gold necklaces in a Dixie cup before going for an X-ray procedure, and they were missing upon her return. The resident's daughter reported the missing necklaces, prompting a search by the facility staff. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were involved in the investigation, which revealed that a Restorative Nurses Aid (RNA) found photos on Facebook of the housekeeper wearing necklaces identical to those of the resident. The housekeeper admitted to taking and pawning the necklaces, which were eventually returned to the resident. The incident caused anxiety and stress for the resident, who had sentimental attachment to the jewelry, particularly a necklace given by her late husband.
Failure to Maintain Corridor Handrails During Renovation
Penalty
Summary
The facility failed to maintain handrails in the corridors for a period of 10.5 months, from June 6, 2023, until April 25, 2024. During an onsite visit from April 24 to April 26, 2024, the surveyor observed that sections of the corridors lacked handrails affixed to the walls. In an interview on April 25, 2024, the Director of Plant Operations confirmed that all handrails were removed on June 6, 2023, due to a major renovation project on the corridor walls. He also stated that the facility had been replacing the old handrails with new ones over the past two weeks, but the project was not yet completed. Furthermore, he admitted to being unaware of the regulatory requirement for corridor handrails to be in place.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plumas District Hospital Dp/snf | 27.6 mi | — | 13 | 0 |
| Tahoe Forest Hospital D/p Snf | 36.2 mi | ★★★★★ | 10 | 0 |
| Caremeridian Llc, Dba Neurorestorative | 39.7 mi | ★★★★★ | 28 | 0 |
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