Inspection·August 15, 2024

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to: Residents Affected - Few 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. Findings: 1. A review of the facility's policies and procedures (P&P) titled, Cleaning and Sanitizing Ice Machines, revised 7/1/21, indicated, Ice machines will be cleaned and sanitized per manufactures guidelines. During a concurrent observation, interview, and record review, on 8/14/24 at 9:25 AM, located in the resident's kitchenette (a small kitchen), the Ice/Water Dispensing machine was observed with Biomed (BM). A white paper towel was used to wipe the water supply nozzle and a moist, black residue was observed. BM stated, the water supply nozzle should be clean and was not. BM stated, the facility utilized an outside contractor to clean the Ice/Water Dispensing machine every six months, per the manufacture's recommendations. BM reviewed the Job Invoice, dated 2/12/24, and stated, the Ice/Water Dispensing machine was last cleaned on 2/1/24. A review of the Ice/Water Dispensing machine's Service Manual, revised 9/24/14, indicated, the maintenance schedule was to be used as a guideline and more frequent maintenance could be required. During an interview on 8/14/24 at 9:30 AM, the Activities Director confirmed, resident drinking water was obtained from the Ice/Water Dispensing machine located in the resident's kitchenette area. 2. A review of the facility's P&P titled, Equipment Management Program, revised 10/1/21, indicated, when there was an equipment failure, facility staff would report the failure to the appropriate department. During a concurrent observation and interview on 8/14/24 at 2:09 PM, located in the kitchen, the drain for the dishwashing machine was observed. Dietary Aide (DA) stated, when draining the dishwasher, DA was required to release the water down the drain, using a stop and go method, so the water would not overflow the drain. DA demonstrated what would happen if DA did not utilize a stop and go (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 08/15/2024 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)