Health inspection·August 1, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings: R1 was admitted to the facility on [DATE] with a diagnosis that included heart failure and falling. R1 requires assistance of staff when getting out of bed and for daily needs. R1 is alert and oriented. R1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS Test) indicating decreased mental functioning. On approximately [DATE], R1 noticed her two gold necklaces were missing. R1 remembered placing the two necklaces in a Dixie cup before going to an X-ray department procedure and they were missing after. R1' daughter reported the missing necklaces to the facility. Facility staff began to search for the necklaces. On [DATE] at 11:00 AM during a concurrent interview and record review the Assistant Director of Nursing (ADON) stated, .we searched. So, then we weren't able to find them and felt there was a possibility they were thrown I the trash because of the cup (being in a Dixie Cup). We still looked and that is when a Restorative Nurses Aid (RNA1) came in with the Facebook pictures. There was (Housekeeper 1[HK1]) wearing similar looking necklaces. So, we went to R1, and she identified them. The photos were provided for review. The ADON continued to state that the Sheriff .went out and spoke to (HK1) and he admitted taking the two necklaces. HK1 then said he had pawned them locally and that he didn't have them anymore. According to the ADON there were further discussions, and the necklaces were returned to R1. On [DATE] at 12:00 PM during a concurrent interview and record review the Director of Nursing (DON) stated, Yes it was reported to us, and we looked high and low for them. All the staff knew and were looking everywhere, and it was RNA1 that found it online. The DON identified photos of the resident wearing the necklaces and online photos of HK1 wearing necklaces identical in appearance. The DON added, She (RNA1) brought in the pictures, and we showed them to R1, and she identified them as hers. On [DATE] during a concurrent record review and interview RNA1 stated, I was looking at Facebook and saw a picture of him and he is wearing two necklaces that looked like (R1's). RNA1 identified printed pictures represented as being from Facebook depicting HK1 wearing the two necklaces. In addition, photos of R1 wearing two substantially similar necklaces were identified. RNA1 stated, Yes, he was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555433 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastern Plumas Hospital- Portola Campus Dp/Snf 500 First Street Portola, CA 96122 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)