Health inspection·January 7, 2025

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based 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.) Residents Affected - Some This failure had the potential to result in an inadequate antibiotic stewardship program to identify potential inappropriate antibiotic use and antibiotic resistance. Findings: A review of Resident 2 ' s medical records indicated a urinalysis (UA-test for bacteria in the urine) was ordered on 12/5/24. Laboratory results indicated a culture and sensitivity (C&S- test to determine the type of bacteria and what antibiotic would treat the infection) which showed positive Escherichia coli. (E.coli-bacteria). A review of Resident 3 ' s medical records indicated a UA was ordered on 12/9/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 4 ' s medical records indicated a UA was ordered on 12/10/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 5 ' s medical records indicated a UA was ordered on 12/19/24. Laboratory results indicated C&S positive for Citrobacter freundii.(bacteria) A review of Resident 6 ' s medical records indicated a UA was ordered on 12/20/24. Laboratory results indicated C&S positive for polymicrobic growth (multiple types of microorganism), probable skin contamination per lab. A review of Resident 7 ' s medical records indicated a UA was ordered on 12/22/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 8 ' s medical records indicated a UA was ordered on 12/25/24. Laboratory results indicated C&S indicated minimal growth. A review of Resident 10 ' s ' medical records indicated a UA was ordered on 12/28/24. Laboratory results indicated C&S positive for Staphylococcus aureus (bacteria). A review of the facility ' s record, [Facility Name] Antibiotic Steward Program (ASP), dated December 2024, indicated 15 residents were monitored for antibiotic use. The record indicated that each (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 3 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 01/07/2025 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)