Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview and resident council minutes review, the facility failed to ensure that three
of eight confidential residents were afforded the opportunity to exercise their right as a a citizen of the
United States when they were not afforded or assisted to vote in the Presidential Election.
This action did not honor residents basic rights.
Findings:
A document titled, Resident Council Meeting Minutes, from 1/31/22 to 11/30/22 (11months) was reviewed.
There was no documentation that residents were informed of their rights to vote at the facility.
On 12/7/22 at 10 am, eight confidential Residents were interviewed. Three of the eight residents stated they
were not offered the opportunity to vote in the Presidential election. One resident stated he would need help
with the ballot. These three residents were assessed by the facility as being cognitively intact. One
resident's Minimum Data Set (MDS, an assessment tool) scored a 14 on their Brief Interview for Mental
Status (BIMS score) and the two other residents had a BIMS score of 15 (13 to 15 suggests residents are
cognitively intact-able to think and reason).
During an interview with the Activities Director (AD) on 12/7/22 at 11:45 am, he stated he typically got
voting ballots sent to the residents in the facility, and then interviewed residents to find out if they want to
vote. He stated he would have to look for any records of this process of who was given the opportunity to
vote and who declined.
On 12/8/22 at 8:45 am, during an interview with the Executive Director (ED), stated the staff
conducting/recording the council minutes should be reviewing and documenting the Residents were
informed of their rights. ED stated the facility would follow the standardized rights that were provided to the
residents on their admission. Under those rights should be the ability to vote during election.
On 12/8/22 at 12:15 pm, the AD was interviewed. AD stated he had no documentation or log to show what
residents in the facility were offered the opportunity to vote, who voted, and who declined during the
Presidential elections. Concurrently during this meeting the Activity Assistant (AA) was interviewed. She
stated she was one of the staff that recorded the council minutes and was present during the meetings. She
stated she has never documented that she had reviewed any of their rights to include their right to vote in
the minutes.
A review of a Standardized Resident [NAME] of Rights, provided by the facility, instructed that
(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 19
Event ID:
555281
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0550
residents would be encouraged and assisted throughout the period of their stay to exercise their rights as a
resident and a citizen.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 2 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0557
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to be treated with respect and dignity and to retain and use personal
possessions.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and review of the provided standardized Residents [NAME] of Rights, one of three
sampled residents was not treated with respect and dignity when he was observed uncovered wearing an
adult brief (diaper) and privacy was not provided (Resident 165).
This violation had the potential for residents rights to not be honored and a potential for psychosocial
distress to occur.
Findings:
Resident 165 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (lack of
adequate blood flow in the brain), heart failure and dysphasia (speech impairment).
A review of a Minimum Data Set (MDS, an assessment tool) dated 11/20/22, indicated the facility was
unable to complete Resident 165's Brief interview for Mental Status (BIMS score, an assessment of mental
status). Resident 165 was also assessed as non ambulatory (walking) and required extensive assistance
from staff for bed mobility, dressing and bathing.
On 12/5/22 at 10:13 am and 4 pm, Resident 165 was observed lying in bed with his lower body uncovered.
Resident 165 was observed wearing an adult brief. His privacy curtain was open and he was exposed to
anyone walking past his room from a main hallway.
On 12/06/22 at 9 am, and 12:22 pm, Resident 165 was again observed lying in bed wearing an adult brief
with no covers on exposed to persons walking past his room. Resident 165 had not been provided pants.
Many staff were observed walking past his room.
On 12/7/22 at 8:10 am, 9:50 am,10 am, and 3:40 pm, Resident 165 was again observed lying in his bed
uncovered and wearing an adult brief.
On 12/7/22 at 4 pm, while observing Resident 165, Registered Nurse (RN) C confirmed Resident 165 was
exposed wearing an adult brief.
On 12/8/22 at 9:50 am, while observing Resident 165, RN B and Certified Nursing Assistant (CNA) G were
interviewed. They both stated they did not know if the facility had tried to put pants on him. They
acknowledged that the reasonable person would not want to let others know they were wearing a diaper.
During an interview with the Executive Director (ED) on 12/8/22 at 3:15 pm, she stated the facility did not
have a policy on privacy and the facility followed the Standardized Resident [NAME] of Rights in their
standard admission agreement.
On 12/12/22 at 8:50 am, the ED stated the facility did not have a policy on dignity. However, stated if staff
noticed Resident 165 uncovered, to at least put pants on to provide privacy.
On 12/12/22 at 10:45 am, Family Member (FM) was interviewed. FM stated Resident 165 was a private
person, and she was glad they put pants on him.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 3 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0557
Level of Harm - Minimal harm
or potential for actual harm
A review of the document provided from the facility titled, Resident [NAME] of Rights, indicated Residents
have the right to be treated with consideration, respect and full recognition of dignity and individuality,
including privacy in treatment and in care of personal needs.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 4 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of two residents (Resident 165)
received reasonable accommodation when the facility did not assess or attempt an alternative call light
when he was unable to use the one that was provided.
Residents Affected - Few
This failed action did not allow Resident 165 the opportunity to call for assistance when needed and the
potential for needs to go unmet.
Findings:
Resident 165 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (lack of
adequate blood flow in the brain), heart failure, and dysphasia (impaired speech).
A review of a Minimum Data Set (MDS, an assessment tool) dated 11/20/22, indicated Resident 165 as
non ambulatory (walking) and required extensive assistance from staff for bed mobility, dressing and
bathing.
During initial tour of the facility on 12/5/22 at 10:13 am, Resident 165 was observed lying in bed. Resident
165 was non verbal and hands were observed to have contracted looking fingers. Family Member (FM) A
was observed sitting next to Resident 165. FM A stated Resident 165 could not use or push his call light.
On 12/7/22 at 8:10 am, Resident 165 was observed lying in his bed and appeared to be watching
television. Resident 165's left arm was positioned above his head, and demonstrated he had movement to
his left arm.
During a concurrent observation and interview on 12/7/22 at 4 pm, with Registered Nurse (RN) C, stated he
did not know if there was a plan in place for an alternative call light. RN C confirmed he had not seen him
use the push button call bell that he was provided.
During a concurrent observation and interview on 12/8/22 at 9:50 am, RN B acknowledged Resident 165
had a new flat call bell now but was on the floor and not within his reach. When RN B handed Resident 165
the pad call light he was able to cradle it with his left hand. RN B acknowledged he had movement to his left
arm. Concurrently, Certified Nurses Aide (CNA) G stated Resident 165 was not able to use the previous call
light that was provided.
During an interview with the Executive Director (ED) on 12/8/22 at 3:15 pm she stated the facility did not
have a policy on call lights.
On 12/8/22 at 4 pm, Resident 165 was observed holding the new pad type call light in his left hand.
A review of Resident165's Activities of Daily Living, (ADL) self care deficit performance care plan (initiated
11/14/22, almost one month ago) indicated Resident 165 was totally dependent on staff for care and the
staff would encourage him to use his bell to call for assistance.
A review of a Physical Therapy Evaluation and Treatment note dated 12/11/22 indicated Resident 165
sustained a cerebral vascular accident (CVA, a stroke) with right hemiplegia (one sided loss of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 5 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0558
movement).
Level of Harm - Minimal harm
or potential for actual harm
On 12/12/22 at 9:05 am, the Director of Rehabilitation (DOR) was interviewed. He stated they do not
always evaluate residents hand function and their ability to use their call light. DOR stated they were never
asked to evaluate Resident 165's ability to use his call light or to evaluate him for a different call bell he
could use.
Residents Affected - Few
On 12/12/22 at 9:15 am, MDS B Nurse stated Resident 165's inability to use call light needed to be
reassessed.
On 12/12/22 at 10:10 am, CNA I stated she has cared for Resident 165 since his admit and has never been
able to use his call bell.
On 12/12/22 at 10:20 am, CNA C stated Resident 165 has not been able to use his call light for the last two
weeks since he cared for him.
During an interview on 12/12/22, at 10:30 am, RN A stated Resident 165 can not use his call light and
believed the facility only has the push button and the pad type. RN A stated did not recall if therapies were
asked to evaluate his ability to use his call light .
On 12/12/22 at 10:55 am the Assistant Director of Nurses (ADON) was interviewed. She stated typically
residents are assessed on admission if they were able to use their call lights and Resident 165 was unable
to stay awake when he was first admitted (11/14/22,close to a month ago).
A review of an undated policy titled, Restorative Program, indicated the program focuses on achieving and
maintaining optimal physical, mental functioning of the resident to attain/ maintain each residents highest
practicable functioning.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 6 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, interview and record review, the facility failed to maintain clean, sanitary and
comfortable assistive devices (wheelchairs) needed for daily living for eight of fifteen sampled residents
(Resident 2, 5, 7, 32, 47, 63, 79 and 92) when their assistive devices were soiled with food debris and
sticky substances.
The failure to ensure a safe and sanitary condition of residents' assistive devices had the potential to cause
cross contamination between residents from micro-organisms present on the soiled wheelchairs and
cushions.
Findings:
1. During a concurrent observation and interview on 12/5/22 at 2:02 pm, Resident 92 stated, while lying in
bed, that his wheelchair was dirty. Resident 92 stated, They need to clean up in here.
During a concurrent observation and interview on 12/5/22 at 2:35 pm, Restorative Nursing Assistant, (RNA)
D and Environmental Services Manager Assistant, (ESM) confirmed Resident 92's wheelchair cushion,
outside of the wheelchair including arm rests, and sides of the wheelchair had sticky substances and food
particles. The back of the wheelchair was soiled where the portable oxygen was stored.
2. During a concurrent observation and interview on 12/5/22 at 2:30 pm, Resident 5 stated My wheelchair
is dirty; they never clean it.
During a concurrent observation and interview on 12/5/22 at 2:32 pm, RNA D and ESM confirmed the
wheelchair in the bathroom of Resident 5 was soiled and had dried food and substances on the cushion,
arm rests and sides of the wheelchair.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date for both Resident 92 and Resident 5's wheelchair were last cleaned on
10/17/2019.
3. During a concurrent observation and interview on 12/5/22 at 2:40 pm, Resident 32 was lying in bed and
his wheelchair was sitting beside the bed. RNA D confirmed observed soiled cushion of wheelchair with a
white-color sticky substance, and the outside of wheelchair, and footrest had both white and yellow-colored
dried substances and food particles.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date that Resident 32's wheelchair was cleaned on 4/20/2020.
4. During a concurrent observation and interview on 12/5/22 at 3:03 pm, Resident 2's wheelchair was
soiled with sticky substances and food particles. RNA D and ESM confirmed wheelchair was visibly soiled
and had food particles.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date that Resident 2's wheelchair was cleaned on 5/20/2020.
5. During a concurrent observation and interview on 12/5/22 at 3:10 pm, Resident 79 was lying in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 7 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
bed with blanket pulled up, and did not communicate. Resident 79's wheelchair and cushion had dried food
particles, and cumulative debris around the arm rests and sides of wheelchair. RNA D and ESM confirmed
the entire wheelchair and cushion was soiled and had dried food particles.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date that Resident 79's wheelchair was cleaned on 9/19/2019.
6. During a concurrent observation on 12/5/22 at 3:15 pm, Resident 47's wheelchair was beside bed and
resident was lying in bed. Wheelchair cushion and all outside areas of the wheelchair had cumulative debris
and food particles. RNA D and ESM confirmed the entire wheelchair and cushion was soiled with food
particles present.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date that Resident 47's wheelchair was cleaned on 9/19/2019.
7. During a concurrent observation and interview on 12/5/22 at 3:23 pm, Resident 63 stated I know they
never clean the room or my wheelchair, they need more help. Wheelchair cushion soiled with dark colored
substance, wheelchair sides and back of chair with cumulative dust and dried debris. RNA D and ESM
confirmed the entire wheelchair and cushion were soiled and had dried dark brownish color debris.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date for both Residents 47 and 63's wheelchair were cleaned on 9/19/2019.
8. During a concurrent observation and interview on 12/5/22 at 3:25pm, Resident 7 was lying in bed and
wheelchair was on the right side of the bed. Wheelchair was soiled, cushion had dried food particles. RNA
D and ESM confirmed the entire wheelchair, and cushion was soiled, and had dried food particles.
A review of a facility document titled, Preventive Maintenance Manual, indicated a cleaning schedule for
wheelchairs. The last recorded date that Resident 7's wheelchair was cleaned on 10/15/2019.
During an interview on 12/5/22 at 11:53 am, with Environmentalist, (E) A stated, We clean the mats and
rooms every day, but I do not clean the wheelchairs.
During an interview on 12/5/22 at 3:33 pm, ESM confirmed the wheelchairs had not been cleaned since
Covid 2020, and stated, We are short staffed, I work 60 hours per week, they are hiring more people.
During an interview on 12/5/22 at 3:45 pm, Maintenance Supervisor (MS) confirmed there was no policy for
wheelchair cleaning, and no process, but he will begin a process for cleaning the wheelchairs. MS stated
We don't have a log for cleaning, we are getting caught up after Covid. ESM works the floor because we
are short staffed. I know we need more help with cleaning.
During an interview on and 12/6/22 at 10:07 am, it was confirmed there was no policy or process for a
scheduled wheelchair cleaning by ESM, and MS.
During an interview on 12/7/22 at 3:54 pm, the Executive Director (ED) confirmed there was no
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 8 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0584
policy for wheelchair cleaning. ED stated, The last time we cleaned the wheelchairs with the exception of
discharges was 2020.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 9 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to revise a care plan for one of of 27 sampled
residents when Resident 165 was not able to use his call light.
This failed action had the potential for care needs not to be identified and met for residents.
Findings:
Resident 165 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (lack of
adequate blood flow in the brain), heart failure, and dysphasia (impaired speech).
A review of a Minimum Data Set (MDS, an assessment tool) dated 11/20/22, indicated Resident 165 as
non ambulatory and required extensive assistance from staff for bed mobility, dressing and bathing.
A review of Resident 165's Activities of Daily Living, (ADL) self care deficit performance care plan (initiated
11/14/22, on admission, greater than a month ago) indicated Resident 165 was totally dependent on staff
for care and the staff would encourage him to use his bell to call for assistance.
On 12/5/22 at 10:13 am, Resident 165 was observed lying in bed. He was non verbal and his hands were
observed to have contracted looking fingers. Family Member (FM) A was observed sitting next to Resident
165. FM A stated Resident 165 could not use or push his call light.
On 12/7/22 at 8:10 am, Resident 165 was observed lying in his bed and appeared to be watching
television. Resident 165's left arm was positioned above his head, and demonstrated he had movement to
his left arm.
During a concurrent observation and interview on 12/7/22 at 4 pm, Registered Nurse (RN)
C stated he did not know if there was a plan in place for an alternative call light. RN C confirmed he had not
seen him use the push button call bell that he was provided.
During a concurrent observation and interview on 12/8/22 at 9:50 am, RN B acknowledged Resident 165
now had a new flat call bell now. Concurrently, Certified Nurses Aide (CNA) G stated Resident 165 was not
able to use the previous call light that was provided.
On 12/12/22 at 10:10 am, CNA I stated she has cared for Resident 165 since his admit and had never been
able to use his push button call bell.
On 12/12/22 at 10:20 am, CNA C stated Resident 165 had not been able to use his call light for the last two
weeks since he cared for him. Concurrently, the same day at 10:30 am, RN A stated Resident 165 can not
use his call light and believed the facility only has the push button and the pad type. RN A stated he did not
recall if therapies were asked to evaluate his ability to use his call light .
On 12/12/22 at 9:15 am, the Minimum Data Set (MDS) B Nurse stated Resident 165's inability to use his
push button call light should have been revised and monitored. MDS B Nurse stated the current
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 10 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0657
plan was contradicting.
Level of Harm - Minimal harm
or potential for actual harm
On 12/12/22 at 10:55 am the Assistant Director of Nurses (ADON) was interviewed. ADON stated typically
residents were assessed on admission if they were able to use their call lights. ADON stated Resident 165
was unable to stay awake when he was first admitted on [DATE], close to a month ago.
Residents Affected - Few
During an interview with the Executive Director (ED) on 12/12/22 at 8:50 am she stated the facility did not
have a care planning policy and the facility practice was to follow the RAI (Resident Assessment
Instrument, a MDS guide for long term care facilities).
A review of the RAI Manual Section 4.7 instructed that patient care plans should be revised on an ongoing
basis to reflect changes and the care they are receiving.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 11 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview the facility failed to provide two of three sampled residents respiratory
care consistent with professional standards of practice (Resident 165 and 169).
Residents Affected - Some
This failure had the potential to cause respiratory infections that could negatively affect residents.
Findings:
On 12/05/22 at 10:13 am, Resident 165 was observed lying in bed wearing oxygen. Next to Resident 165,
on a bedside table a portable suction machine was observed. The tubing from the suction machine and a
Yankar (brand of a suctioning tool put at the tip of the tubing) was not dated to indicate when the tubing or
Yankar had been last replaced. The Yankar was in a opened plastic wrapper.
During an observation on 12/05/22 at 10:23 am, Resident 169 was observed lying in bed wearing oxygen.
A nebulizer (a machine that delivers areola medication) was observed on Resident 169's bedside table. The
tubing attached to a mask was observed dated 11/28/22. A wheelchair with an attached portable oxygen
tank was also observed at this time located by Resident 169's bed. The tubing attached to the portable
oxygen tank was dated 11/28/22.
On 12/05/22 10:23 am, a Licensed Nurse (LN) B was interviewed. LN B acknowledged the above observed
nebulizer on Resident 169's bedside table dated 11/28/22. She stated the night shift is responsible for
changing the oxygen/nebulizer tubing weekly and Resident 169's must have gotten missed last night.
On 12/8/22 at 8:45 am, the suction machine in Resident 165's room was observed again with Registered
Nurse (RN) B. RN B acknowledged the suction machine tubing and Yankar suction piece was not dated as
to when they had been replaced. RN B stated Resident 165 can not suction himself and nursing has to
assist him.
On 12/12/22 at 9 am, the Executive Director (ED) was interviewed. She stated the facility did not have a
policy for changing oxygen tubing and the Yankar. ED stated the facility's practice was to change the tubing
weekly and the Yankar daily. The ED stated the changes were not recorded in the Residents Treatment
Administration Records (TARS).
During an interview with the Infection Preventionist Nurse (IP) on 12/12/22 at 9:20 am, she stated it was the
facility practice and standard to change and date oxygen tubing every week. IP stated the Yankar suction
device should be changed and dated daily.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 12 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0810
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide assistive adaptive equipment for two of
six residents (Resident 67 and 83) while eating in the dining room when:
Residents Affected - Few
1. Resident 67 did not have adaptive equipment (sippy cup with straw) for eating on meal tray.
2. Resident 83 did not have adaptive equipment (sippy cup) for eating on meal tray.
This failure had the potential to not meet the nutritional and hydration needs for these residents.
Findings:
1. A review of the facility's policy titled, Regular Diet-Finger Foods, dated 2020, indicated Adaptive
equipment such as plate guards, sippy cups, divided plates, soup bowls, mugs or cups with one or two
handles are to be used for residents with Alzheimer's disease or inadequate digital dexterity.
A review of the record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that
included dementia, neurologic neglect syndrome, (a syndrome characterized by sensory loss of stimuli,
surroundings) and muscle spasms.
During an observation on 12/6/22 at 12:52 pm, Resident 67's meal tray did not include sippy cup with straw
as ordered by the physician.
A review of Resident 67's Physicians Orders titled, Active Orders as of 12/6/22, indicated Regular diet,
regular texture, thin consistency, finger foods, sippy cup with straw for liquids at all meals, one to one
supervision.
A review of the record titled, Care Plan, initiated on 10/30/22, indicated Registered Dietician (RD) added
the following interventions: One to one meal assistance, North dining room for meals as tolerated, provide,
and serve diet as ordered: Regular finger foods, sippy cup with straw for fluids.
2. A record review indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included
Parkinson's disease (a brain disorder that causes unintended movements such as shaking, stiffness),
dementia and dysphagia (difficulty swallowing).
During an observation on 12/6/22 at 12:54 pm, Resident 83's meal tray did not include sippy cup as
ordered.
A review of Resident 67's Physicians Orders titled, Active Orders as of 12/6/22, indicated Mechanical soft
diet texture, thin consistency, small portions, one to one feeder, and swallow precautions.
A review of the record titled, Care Plan, initiated on 6/29/22, indicated the use of adaptive devices as
recommended by therapy or physician, monitor for safe use. Monitor and document to ensure appropriate
use of safety, and assistive devices, diet as ordered.
During an interview on 12/6/22 at 12:57 pm, Registered Nurse (RN) C confirmed he missed the sippy
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 13 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0810
Level of Harm - Minimal harm
or potential for actual harm
cup ordered for Resident 67 and Resident 83 when checking all the trays before the staff began to assist
with feeding.
During an interview on 12/6/22 at 1:01pm, Certified Nursing assistant, (CNA) E and CNA F, confirmed there
was no sippy cup for both Residents 67 and 83 on their meal tray as ordered by the physician.
Residents Affected - Few
During an interview on 12/6/22 at 3:20 pm, Certified Dietary Manager (CDM) confirmed no sippy cups
placed for both Residents 67 and 83. CDM stated to order more sippy cups because the nursing staff were
slow to return all adaptive equipment back to the kitchen.
During an interview on 12/6/22 at 3:50 pm, the Executive Director (ED) confirmed the LN (Licensed
Vocational Nurse) or RN was supposed to make sure all adaptive equipment was on meal trays before the
CNAs supervised and assisted with feeding for all residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 14 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure safe and sanitary food
preparation and storage practices in the kitchen when:
Residents Affected - Some
1. The blue plastic holder for the can opener and the base was unsanitary.
2. The food processor had dried food particles and was unsanitary.
3. Two of the kitchen drawers had dried, brown-colored debris on the inside of drawer which
stored cooking utensils.
4. Cooking utensils had dried food particles.
5. The chipped paint on white shelves in the three-door reach in refrigerators were not easily
cleanable.
6. Four dry storage bins had white and yellow-colored dried sticky substances on the lids and
bottom of bins.
7. The flour in the dry storage bin was expired; expiration date labeled 10/12/22.
These failures had the potential to result in cross contamination and foodborne illness.
Findings:
1. During a concurrent observation and interview on 12/5/22 at 9:26 am, the blue plastic piece of the can
opener holder was filled with yellow slime, the metal base of the can opener was full of black debris.
Prep-cook (DC) A stated, This can opener base has to be removed to be cleaned properly. The Certified
Dietary Manager (DSM) confirmed the blue plastic piece of the can opener stand had not been cleaned per
cleaning schedule and the base of the can opener needed to be completely removed. DSM stated, I am
ordering a new type of can opener for the kitchen. DC A and DSM confirmed this unclean can opener base
could contaminate food and cause food-borne illness.
During a follow up interview on 12/8/22 at 2:30 pm, DSM confirmed a new order of can opener and was
using a portable one until the new one arrived.
A review of the policy titled, Can Opener And Base, dated 2018, indicated to wash the base with a brush,
and cloth, and a detergent solution following manufacturer's instructions. Make sure the shaft cavity is
clean. Rinse with fresh water and dry thoroughly with a clean cloth. Number five stated to clean the base at
least once every three months, the underside of the base should be cleaned as well as the table where the
base rested.
2. During a concurrent observation and interview on 12/5/22 at 9:24 am, DC A and DSM confirmed the food
processor had dried food in the plastic container for chopping foods, and the food processor
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 15 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
base had dried food particles. Both DC A and DSM confirmed these unclean parts of the food processor
could lead to cross contamination and potentially cause food-borne illness.
A review of a policy titled, Electrical Food Machines, dated 2018, indicated to wash after each use, (always
unplug before cleaning). It indicated to remove adjustment ring, knife, and plate. Wash in dishwasher and
allow to air-dry thoroughly. Wash, rinse, dry the other parts of the grinder, which do not come in contact with
food, such as the base. Food grinder should be covered when not in use.
A review of the Federal Food and Drug Administration (FDA) 2017 Food Code §4-903.11 Equipment,
Utensils, Linens, and Single-Service and Single-Use Articles. Cleaned equipment and utensils, shall be
stored: (1) In a clean, dry location.
3. During a concurrent observation and interview on 12/5/22 at 9:21 am, two separate kitchen drawers
storing cooking utensils were soiled and a brownish-color debris observed on the inside of drawers, both
the top of the inside of drawer and the bottom of the two drawers. The DC A confirmed these unsanitary
drawers could lead to cross contamination and food-borne illness.
A facility policy titled, Cabinets and Drawers,dated 2018, indicated to clean cabinets and drawers weekly
with the use of a mild detergent per manufacturer's instructions and water. Removable drawers should be
removed and washed. Rinse shelves and drawers with a clean sponge and dry.
4. During a concurrent observation and interview on 12/5/22 at 9:22 am, three cooking utensils had dried
food substances. DSM confirmed cooking utensils had dried food particles and removed all utensils from
two drawers to rewash. DSM stated these unclean cooking utensils had the potential to cause food-borne
illness.
According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept
free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on
nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which
employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide
harborage for insects, rodents and other pests.
5. During a concurrent observation and interview on 12/5/22 at 9:19 am, chipped paint was noted on all
white plastic shelves in the three-door refrigerator. Both DC A and DSM confirmed all shelves need to be
replaced and were not easily cleaned due to the chipped paint and this could potentially lead to food-borne
illness.
A facility policy titled, Refrigerator and Freezer, dated 2018, indicated to periodically inspect shelves and
replaced if coating was chipped away exposing metal shelves.
6. During a concurrent observation and interview on 12/5/22 at 9:26 am, four of four dry food storage bins
had white and yellowish-colored sticky substances on all the covered lids. The DC A and the DSM
confirmed these unsanitary dry food storage bins could lead to cross contamination and food-borne illness.
A facility policy titled, Ingredient Bins, dated 2018, indicated to scrub the interior and the exterior of the bin
with detergent solution. Pay special attention to the corners, lids, and casters.
7. During a concurrent observation and interview on 12/5/22 at 9:30 am, one storage bin full of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 16 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
flour for cooking had the expiration date of 10/12/22. Both the DC A and DSM confirmed this date labeled
on the flour bin was expired for almost two months.
A facility policy titled, Storage Of Food And Supplies, dated 2018, indicated bins and containers were to be
labeled, covered, and dated. Dry food items which have been opened, will be tightly closed, labeled, dated,
and used per times specified in the dry food guidelines.
Event ID:
Facility ID:
555281
If continuation sheet
Page 17 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview and record review, the facility failed to provide a safe, functional, and
sanitary shower room for one of three shower rooms and a clean living environment for two residents when:
Residents Affected - Some
1. The shower room was not functioning properly, unsanitary and needed maintenance.
2. Two Residents (Resident 63 and 92) had unsanitary living-areas.
This failure to ensure a safe and sanitary shower room and residents' rooms had the potential to harbor
bacteria growth, and the potential to cause cross contamination between residents from micro-organisms.
Findings:
1. A review of the facility's policy titled, Bathtubs, Showers Cleaning Procedure, reviewed in 9/2016,
indicated to mix approved germicidal detergent solution in a bucket. In event of stains, use cream cleanser
to remove stains. Using a clean cloth, scrub all porcelain surfaces, tub, shower, sink and toilet in bathing
area. Wipe all porcelain surfaces with a clean dry cloth to avoid water spotting. It further indicated, in
shower and tub area where you have tile walls, wash down the tile walls using hospital approved germicidal
detergent solution.
During an interview on 12/8/22 at 7:20 am, Resident 63 stated, Can you look at the shower room? There is
mold, and it is nasty.
During an observation on 12/8/22 at 7:50 am, the shower room was unsanitary, unkept and the shower
head was leaking. There was a missing tile and concrete showing under the shower head area. Areas of
white caulking were also missing around the entire shower area.
During a concurrent observation and interview on 12/8/22 at 8:30 am, Licensed Nurse, (LN) A and
Environmental Services Manager Assistant (ESM) confirmed the bathing area was not sanitary, the shower
head was leaking, the caulking around the shower was missing in specific areas, there was no tile under
the shower head and the concrete was showing in shower room of the 200 hall.
During an interview with the Maintenance Supervisor (MS) on 12/8/22 at 9:58 am, confirmed the shower
room needed repair and was not sanitary. Shower room for the 200 hall was closed for maintenance
needed on 12/8/22 at 9:58 am. MS stated, I am closing the shower room for repair, leaking shower head,
replacing tile and caulking. The staff never waits long enough for it to dry, we will repair, and it needs to set
for at least a day and a half or two days to stay.
2. A review of the facility's policy titled, Deep Cleaning of Patient Room, undated, indicated the following:
Wipe all furniture, chairs, bedside tables, and over-bed tables. Wipe inside all drawers. General dust, wipe
down all horizontal surfaces. Evaluate the condition of draperies and cubicles for cleanliness. Damp/Dust
mop the floor. Damp mop the floor. Clean the baseboard if needed. Spot clean walls for food spots, etc.
Report to the nurse that the room is complete.
During an observation on 12/5/22 at 11:26 pm, Resident 92's room was unsanitary and the brown mats
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 18 of 19
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
555281
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oroville Hospital Post-Acute Center
1000 Executive Parkway
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 0921
bedside each side of the bed for fall risk were covered with food particles.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 12/5/22 at 11:53 am, Environmentalist (E) A confirmed Resident 92's room and
living area were dirty, E A stated, I have not got to that room yet. I clean the room and mats.
Residents Affected - Some
During an interview on 12/5/22 at 11:58 am, MS and ESM confirmed they needed more staff, and Resident
92's room had not been cleaned yet.
During a concurrent observation and interview on 12/5/22 at 2:10 pm, Resident 92 stated, They need to
clean up in here. Resident's room was unkept, with black colored dried debris on the floor, and a sticky
substance on the floor tile.
During a concurrent observation and interview on 12/8/22 at 7:20 am, Resident 63 stated The area under
my heater has dirt, I have asked them over and over to clean, they never do it. The area around heating unit
had black debris, which was unable to have been wiped up.
Resident 63's living area was unsanitary, and the floor was sticky, soiled with brown and black areas, trash
was visible in the floor.
During an interview on 12/5/22 at 3:45 pm, MS stated We don't have a log for cleaning, we are getting
caught up after Covid. ESM works the floor because we are short staffed. I know we need more help with
cleaning.
During an interview on 12/8/22 at 7:40 am, Licensed Nurse (LN) A confirmed Resident 63's room was
unsanitary, and Resident 63 did not go out for physician appointments for deep cleaning to be completed.
During an interview on 12/8/22 at 8:35 am, ESM confirmed deep cleaning had not been completed for
Resident 63's room in over a year since she moved. ESM stated, I never got to her room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555281
If continuation sheet
Page 19 of 19
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
9 citations 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the December 12, 2022 survey of OROVILLE HOSPITAL POST-ACUTE CENTER?
This was a inspection survey of OROVILLE HOSPITAL POST-ACUTE CENTER on December 12, 2022. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OROVILLE HOSPITAL POST-ACUTE CENTER on December 12, 2022?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.