Health inspection·August 1, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete out of 15 and was cognitively intact (able to think and reason). During an interview on 7/10/25 at 3:20 pm, Resident 2 stated, I was sitting at my doorway, and I asked [Resident 3] to stop talking so loud and to leave the room, he just hit me in the eye. I admit, I probably yelled at him before he hit me because I am hard of hearing (HOH). It just all happened so fast. I did feel discomfort for a few days. During an interview on 7/10/25 at 3:50 pm, Resident 3 stated, Listen, I know it was wrong, I just have a lot of stress on me, it just happened. I never planned to hit [Resident 2]. I just had a reaction to his yelling. I was just trying to talk with my friend that also lives in that room. I told him I was sorry; I never meant to hurt him. During an interview on 7/10/25 at 4:25 pm, Registered Nurse (RN) B stated, I was in another room, and we heard a lot of yelling. I along with other staff went into the room but [Resident 3] had already hit [Resident 2] in the eye. Two men fighting is what happened. We then called 911 and sent [Resident 2] to the hospital to make sure he was okay. During an interview on 7/10/25 at 5:45 pm, the Director of Nursing (DON) confirmed Resident 2 was physically abused by Resident 3. DON stated, [Resident 2] did have a Right black eye for a few days, and I do confirm he stated he was having discomfort. During a phone interview on 7/17/25 at 12:30 pm, the administrator confirmed Resident 3 physically abused Resident 2 when he was hit in the right eye. Event ID: Facility ID: 055612 If continuation sheet Page 2 of 4 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 055612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Feather River Care Center 1 Gilmore Lane Oroville, CA 95966 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)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility's nursing staff failed to recognize and report a change in condition for one of eight sampled residents (Resident 7). This failure caused Resident 7 to have a delay in acute care treatment required, and the need for new placement after a hospitalization related to the lack of communication when Resident 7 had a change in condition.A review of the facility's policy revised 8/2024, titled, Notification of Changes, indicated the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. During a review of Resident 7's medical record, the admission Record, indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular and fast heart beat), aortic valve disorder (a major heart valve that narrows, decreases blood circulation), bilateral pneumonia (infection of both lungs), Bi-polar disorder (mental health condition with severe mood changes), Chronic Obstructive Pulmonary Disease (COPD, a chronic and progressive lung disease), Major depressive disorder (prolonged feelings of sadness, hopelessness and loss of interests), history of sepsis (a severe reaction to an infection), benign prostatic hyperplasia (BPH, enlarged prostate), hyponatremia (low level of sodium in the blood), history of venous thrombosis and embolism (a blood clot that travels to the lungs) and schizophrenia (a condition that has severe effects on your physical and mental well-being. It disrupts how your brain works, interfering with things like your thoughts, memory, senses and behaviors). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 6/17/25, indicated that Resident 7 had a Brief Interview for Mental Status, (BIMS) score of 15 out of 15 and was cognitively intact (able to think and reason). During a review of Resident 7's medical record, a document dated 7/2/25, titled, Blood Pressure Summary, the blood pressure (B/P, measured by two numbers, the top number systolic when your heart beats, and the bottom number diastolic is when your heart rests by Millimeters of Mercury, (mmHg, a unit of measure) normal range for B/P adults are 120/80. Resident 7's B/P was documented at 82/64 mmHg with a note that indicated the following: Systolic low of 90 exceeded. During a review of Resident 7's medical record, a document dated 7/2/25 at 8:07 pm, titled, Progress Note, indicated Resident 7's blood pressure was 82/64 mmHg, and this note did not indicate more than one measurement, or which position Resident 7 was in when taking the B/P. MD orders to push fluids, but no noted documentation to send Resident 7 for an evaluation. This progress note indicated resident was own Responsible Party (RP). During a review of Resident 7's medical record, a document dated 7/2/25 at 11:32 pm, titled, Progress Note, indicated the following: At about 22:25 the cops arrived at facility. The cops went in to see resident. Resident was talking on the phone with daughter at the time the cops arrived. Per resident and daughter's request, resident agreed with his daughter to be sent out to the hospital due to daughter's concern of resident's possible allergic reaction to Buspirone. Resident has NKA and did not show any signs of allergic reactions prior to being discharged . Resident is his own RP. MD notified and aware. During a review of Resident 7's medical record, a document dated 7/2/25 at 11:57 pm, titled, Progress Note, indicated the following: Police officers spoke with resident, and after a half hour, officers inform nurse that resident would like to be sent out to the hospital, per his request (resident full code). Notified MD at 22:51, given okay. Called EMS at 22:51 to request transfer. 2300 EMS arrives to take resident via gurney to hospital. Resident brought along his Continuous Positive Airway Pressure (CPAP, machine), a suitcase, wallet, and a black bag. Resident was on phone with daughter on speaker phone, having EMS repeat conversation having in room. Daughter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055612 If continuation sheet Page 3 of 4 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 055612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Feather River Care Center 1 Gilmore Lane Oroville, CA 95966 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)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated she is recording conversation. Resident stated that he did not want to come back and was informed that a family member may return to pick up the rest of his belongings. EMS left the facility with resident at 23:25. During a concurrent interview and record review on 7/10/25 at 5:25 pm, the Director of Nursing (DON) confirmed the Family Member (FM) should be updated with any change of condition even if they are their own RP by the nursing staff. DON confirmed their facility policy for change of condition was not followed for Resident 7. The DON agreed the FM and Resident 7 were upset and this was avoidable if their policy had been followed. During a follow-up interview on 7/10/25 at 5:40 pm, the DON confirmed Resident 7 had a change of condition with an extremely low blood pressure and should have been sent to the local hospital for an evaluation without the police being called for help on 7/2/25. DON stated, I confirm Resident 7 had a delay in care and should have been sent out to the local hospital earlier. I do confirm Resident 7 was admitted to a local hospital for an extended period, and they were not happy with the care at this facility. Event ID: Facility ID: 055612 If continuation sheet Page 4 of 4