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Inspection visit

Health inspection

FEATHER RIVER CARE CENTERCMS #0556121 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 (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: 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 01/29/2026 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)
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 055612 If continuation sheet Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the January 29, 2026 survey of FEATHER RIVER CARE CENTER?

This was a inspection survey of FEATHER RIVER CARE CENTER on January 29, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at FEATHER RIVER CARE CENTER on January 29, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.