Inspection·March 25, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on Interview and Record Review, the facility failed to meet this requirement when a staff member spoke to a resident (Resident 1) in a manner the resident perceived as disrespectful. This had the potential to result in psychological harm to Resident 1 and compromised the resident's sense of well-being and feeling of being in a home-like environment. Resident 1 was admitted to the facility for conditions including age-related debility (unable to perform tasks that are part of daily living), arthritis, and heart disease. A review of the facility's policy titled, Elder or Dependent Adult Abuse Reporting indicated that each resident shall be treated as an individual with dignity and respect and shall not be subject to abuse of any kind. The policy further defined abuse as including verbal abuse. Review of Resident 1's Minimum Data Set (a series of tests for residents' functional and mental abilities) that was performed by the facility on 12/7/24 (Section GG) indicated that she needed Substantial/Maximal Assistance for most activities, including toileting. Her functional and mental abilities test (MDS Section C) indicated that she was cognitively intact (no memory or communication problems). In an interview on 3/25/25 at 1:00 PM, Resident 1 confirmed that she is frequently incontinent (unable to control her bowel and bladder) and relies on staff assistance. Resident 1 stated that because she is often vocal about her concerns, she has a history of conflicts with the facility's Director of Nursing (DON A) that in some instances had to be mediated by an outside community advocate for the aging. Resident 1 stated that on or around 2/27/25, Director of Nursing (DON A) and LVN B both responded to her request to have her disposable brief changed. Resident 1 stated that she had joked with the two nurses, stating, Well, here come Wonder Woman and Hercules. Resident 1 stated that DON A's response to this was: I could let you sit in a wet diaper . Resident 1 stated that her history of butting heads, with the DON and that she interpreted the remark as disrespectful in light of their poor relationship. Resident 1 stated that she felt angry about the situation because this is my home. I have to be here for the rest of my life. Resident 1 further stated that she wanted to report the incident and was surprised that someone else reported it for her, and that she had disclosed it to certain nursing staff but could not remember to whom. In an interview on 3/25/25 at 2:10 PM, Assistant Director of Nursing (ADON B) stated she had not witnessed the incident, but that the statement I could let you sit in a wet diaper, would be (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 03/25/2025 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)