Health inspection·January 13, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that four out of four sampled residents (Residents 1, 2, 3, and 4) had an individualized smoking safety care plan that identified smoking-related risks, resident-specific interventions, and safety measures. Despite the facility's knowledge that these residents smoked, there was no documented care-planning process to address smoking supervision, designated smoking location, safety precautions, or ongoing evaluation and revision of the plan of care.This failure resulted in residents not receiving individualized, person-centered care related to smoking safety, with smoking-related risks remaining unrecognized and unmet, and had the potential to place residents at risk for decline in health status, including injury or other adverse outcomes.During a review of the facility's policy and procedure titled Resident Smoking - Smoke-Free Facility, revised 12/1/25, the policy stated that any resident deemed safe to smoke, with or without supervision, will be allowed to smoke only in designated smoking areas in accordance with the resident's care plan. The policy further stated that all safe smoking measures will be documented in each resident's care plan and communicated to all staff, visitors, and volunteers responsible for supervising residents while smoking, and that supervision will be provided as indicated on the resident's care plan. The policy also stated that if a resident or family does not abide by the smoking policy, the plan of care may be revised to include additional safety measures.During record reviews on 12/19/25, Residents 1, 2, and 3's care plans and physician orders dated December 2025 were reviewed. The care plans lacked documented, individualized interventions to support safe smoking practices, including supervision requirements, designated smoking areas, or other smoking-related safety measures.A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included COPD, Tobacco use, alcohol abuse, ataxia following cerebral infarction, and other psychoactive substance dependence with intoxication delirium. Resident 1's brief interview for mental status (BIMs) score was 15, indicating Resident 1 was cognitively intact.During a review of Resident 1's Interdisciplinary (IDT) Progress Note, dated 12/17/25, the IDT note indicates, despite education the resident continues to smoke cigarettes on facility grounds. Resident has been observed smoking near hazardous areas and sneaking out multiple times during the day and night. Nicotine patch therapy was initiated but Resident refuses to use patches and continues to obtain cigarettes and lighters from outside sources. The note also indicates that the care plan is to be updated to reflect elopement risk, substance use behaviors and refusal of nicotine replacement therapy.During a review of Resident 1's care plan, dated 11/26/25, the Care Plan did not indicate elopement risk or any kind of safe smoking plan.During a review of Resident 2's medical record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that include schizoaffective disorder, muscle weakness with frontal lobe and executive function deficit. Resident 2's brief interview for mental status (BIMs) score was 15, indicating Resident 2 was cognitively intact. (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: 055612 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 01/13/2026 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)