Health inspection·January 29, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to protect two of two sampled Residents (Resident 1 and Resident 2) while performing wound care when the cleaning and sanitizing of the surgical scissors was not done between each use.This failure had the potential to cause widespread infection among the residents.Findings:A review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment dated 1/1/2026, indicated, Staff Shall follow established infection control principles for cleaning and disinfecting reusable; non-critical equipment general guidelines include.d. Multiple resident use equipment shall be cleaned and after each use.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included difficulty walking, need for assistance with personal care, diabetes and pressure ulcer of the left heel. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included, need for assistance with personal care, diabetes and chronic ulcer (open sore or wound that fails to heal), of other part of right foot.During interview on 1/22/26 at 10:30 am, in Resident 1 & 2's room (Resident 1 and 2 were roommate), Resident 1 stated he came to the facility with right and left heel wounds. Resident 1 stated the right heel healed and the left is receiving treatment and dressing changes. Resident 1 described his morning routine as being woken up between 5-6 am. Resident 1 stated he is not offered a cloth to wash his face and hands. He stated he does not receive showers, only sponge baths twice a week, Resident 1 is unable to stand in a shower due to his heel wound.During an interview on 1/22/26 at 10:28 am, in Resident 1 & 2's room, Resident 2 stated he came to the facility with a diabetic ulcer on his right foot. Resident 2 stated he is supposed to get a shower twice a week. Resident 2 stated he must ask for his care, including wash clothes to clean his face and hands.During observation on 1/22/26 at 11:20 am, in Resident 1 & 2's room, observed Licensed Vocational Nurse (LVN A) performing wound treatment to Resident 1's left heel. LVN A gathered needed supplies to complete task. LVN A reviewed Physician order for treatment. LVN A began with soaking gauze with saline due to gauze being stuck to the left heel. After saturated by saline, removed the wet gauze and dabbed the heal dry. LVN A removed scissors from her pocket to cut special dressing Calcium Alendronate. LVN A applied the dressing to the heel, covered with 4 centimeter by 4 centimeter (cm) gauze then wrapped with gauze dressing and taped. Observed the tape indicated date and initials. LVN A then placed the uncleaned scissors in her pant pocket.During Observation on 1/22/26 at 11:40 am, in Resident 1 & 2's room, observed LVN A performing wound treatment to Resident 2's right heel. LVN A gathered needed supplies, reviewed Physician orders. LVN A began removing gauze dressing with minimal use of saline. After dressing and gauze were removed, dabbed the heel dry. LVN A then removed the scissors that was previous used on Resident 1 from her pant pocket, cut the special dressing Calcium Alendronate then applied 4 cm by 4 cm gauze to cover special dressing. Wrapped the heel with gauze dressing and taped. Observed tape indicated date and initials. LVN A disposed of trash and soiled towel. Observed Residents Affected - Some Page 1 of 2 055612 055612 01/29/2026 Feather River Care Center 1 Gilmore Lane Oroville, CA 95966

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN A place the scissors in pant pocket. Observed LVN A did not clean the scissors after resident.During interview with LVN A on 1/22/26 at 1:52 pm, when asked about the process of wound change and using personal scissors when working with multiple patients. LVN A stated she forgot to sterilize the scissors in between each resident. LVN A stated standard is to sterilize equipment between residents.During interview with Infection Control (IP) at 1:54 pm, when asked the expectation of nurses working with multiple patients using personal scissors IP stated, the expectation is to disinfect instruments between residents. 055612 Page 2 of 2