Inspection visit

InspectionJanuary 18, 2022

COUNTRY CREST POST-ACUTECMS #55580216 citations on this visit

16 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of Resident 7's record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. MDS, dated [DATE], indicated Resident 7 had severe cognitive impairment (unable to think and reason), total dependence for activities of daily living (ADLs), and required two person assistance for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and toilet use. Resident 7's range of motion was impaired on both sides of her upper and lower extremities, and used a wheelchair for mobility. A review of Resident 7's Nurses Progress Note, dated 10/22/2021 at 6:21 AM by Licensed Nurse (LN) F, indicated Resident 7 had a witnessed fall. Certified Nursing Assistant (CNA) D informed LN F that on her last round at 5:20 AM, Resident 7 had fallen out of bed onto the floor while being changed by CNA D. CNA D stated she didn't see Resident 7 hit her head on the floor, as the pillow came along with the resident onto the floor. LN F assessed Resident 7 right away, and noted skin tears on upper left elbow, and a bigger skin tear on lower left forearm. LN F also noted discoloration to Resident 7's left forehead, and redness on her upper back. A review of Resident 7's Care Plan, initiated 10/21/2021, indicated she was non-ambulatory, dependent for all ADL care, and at risk for falls related to dementia, immobility, gait/balance problems, and incontinence (lack of voluntary control over urination or defecation). Resident 7 was at risk for accidental injury during ADL care. Resident 7 had actual pain related to a fall from bed to floor on 10/22/2021. New intervention, dated 10/26/2021, indicated Care-giver retraining on fall precaution and 2 person bed mobility safety. A review of Resident 7's Interdisciplinary Team (IDT, a team of health care professionals who assess, coordinate, and manage each resident's care) Progress Note, dated 10/25/2021, indicated she had an witnessed fall from bed on 10/22/2021 at 5:20 AM, during incontinence care by one staff. Resident 7 had rolled off her bed and sustained skin tears to her left arm. Resident 7 was noted to have discoloration to left side of face. She was sent to the hospital emergency department for evaluation, and returned to the facility. Root cause analysis indicated Resident 7 was totally dependent for care, and was two person assist at the time of the accident. Staff did not follow facility policy/procedure for two person assist. Resident 7's care plan was updated with new intervention: re-educate the staff on having two staff in the room, one on each side of the bed during care. During an interview on 1/12/2022 at 11:20 AM, CNA E stated Resident 7 was non-verbal, unable to make her needs known. and was totally dependent on staff for ADLs and care. (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 35 Event ID: 555802 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/12/2022 at 5:58 PM, CNA D stated she was assigned care for Resident 7 on 10/22/2021. CNA D stated she was making her final resident rounds on night shift, and decided to change Resident 7, as the resident was incontinent. She stated when she rolled the resident towards her on the bed, the resident was too close to the edge of the bed, and Resident 7 rolled onto the floor. CNA D stated she immediately checked the resident for any injury, and noted that Resident 7 had sustained some skin tears. She notified the nurse immediately, who assessed Resident 7. CNA D assisted the nurse in getting Resident 7 back into bed, using a resident lift. CNA D stated that at the time of the incident, Resident 7 was one person assist for incontinence care, and did not require two staff to change the resident. CNA D stated Resident 7 was two person assist for transfers, using a resident lift. She stated the nurse was busy at the time giving medications to another resident. CNA D stated staff education was provided following the incident on use of the resident lift, as well as instruction to always use two staff at all times, when providing care to Resident 7. During an interview on 1/13/2022 at 6:25 AM. Licensed Nurse (LN) F stated she was the nurse on duty on 10/22/2021 when Resident 7 rolled out of bed. LN F stated CNA D was changing the resident at the time of the incident. LN F stated she and CNA D were the two staff assigned to resident care on NOC shift for Unit A. LN F stated that CNA D was working with Resident 7 by herself at the time of the incident, and reported the incident to her right away. LN F stated Resident 7 was total care and non-verbal, so she assessed the resident's pain by looking for grimacing (to distort one's face in an expression of pain). LN 7 stated that following the incident, education was provided to CNA staff to always have two staff present when providing care to Resident 7. A review of the facility's policy/procedure titled, Safe Resident Handling and Movement, revised 11/2012, indicated daily staff assignments would include a buddy for assistance when moving or repositioning a resident. If a buddy was not available, another staff would be requested to assist with the resident. During a concurrent interview and record review on 1/13/2022 at 1:36 PM with Director of Nursing (DON), Resident 7's record was reviewed. DON confirmed that Resident 7 had fallen from bed while receiving care from CNA D, on 10/22/2021. DON stated the incident happened because CNA D had not followed the facility's standard of practice for two staff members present, one on either side of the bed, when positioning totally dependent residents. DON stated that Resident 7 was totally dependent, and had been for several years prior to the incident. DON stated an x-ray had been taken of the resident's elbow following the resident's return from an evaluation at the hospital, as the resident had discomfort/pain in their elbow after the fall. Based on observation, interview and record review, the facility failed to ensure staff supervision and implemented care plan interventions to meet the needs of the residents for four of four residents when: 1. Resident 244's fall mat equipment was not used as per manufacturer's recommendation. This failure put Resident 244 at risk for continued accidents and hazards. 2. Resident 7 rolled out of bed when she did not receive required assistance during care. This failure resulted injuries that required evaluation and treatment at hospital emergency department. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 2 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0689 3. Resident 19's care plan was not implemented. Level of Harm - Minimal harm or potential for actual harm This failure resulted in Resident 19's right arm to be entrapped in bedrail and had the potential for injury. Findings: Residents Affected - Some A review of the facility's policy titled, Safety and Supervision of Residents revised September 2011, indicated: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents; 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the Minimum Data Set (MDS resident assessment); 3. The interdisciplinary (IDT- group of healthcare disciplines that meet to discuss resident care needs) care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents; 4. Implementing interventions to reduce accident risks and hazards shall include .a. communicating specific interventions to all relevant staff, d. ensuring that interventions are implemented, and e. documenting interventions. 1. Resident 244 was admitted to the facility on [DATE] with diagnoses that included an abdominal aneurysm (swollen vein with potential to burst), dementia (brain decline), general weakness, a history of syncope (fainting), and repeated falls. A review of the most recent MDS dated [DATE], indicated Resident 244 was cognitively intact (able to think and reason) and required limited assistance for bed mobility and transfer. A review of Resident 244's Care Plan, initiated 12/21/2021, indicated that he was at Risk for Falls related to a history of falls, poor safety awareness, impulsive behavior, with the goal, Resident will be free from falls. Interventions to include; alarm pad to alert staff when resident is making unsafe actions, and utilize devices as appropriate to ensure safety such as bed mats, etc. A review of Resident 244's record indicated he had two falls since admission, on 1/2/2022 and 1/3/2022 both as unwitnessed falls. Both of these falls required a trip to the emergency room for evaluation. On 1/10/2022 at 3 PM, it was observed that the facility had stacked two mats on either side of the resident's bed; one that appeared to be a thinner alarm mat, and another thicker beveled rubber mat. The mats were observed to be stacked in a manner that created a flap suspended with an open gap over the lower mat. In an interview on 1/10/22 at 3:28 PM, Responsible party (RP2), stated that after the resident arrived on 12/21/2021, there were fall mats by his bed, but they were taken away at points by staff with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 3 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0689 Level of Harm - Minimal harm or potential for actual harm no explanation. When she asked that they be replaced, the facility replaced them. After he fell, we did not want him to come back here. He was supposed to have supervision. He is now confused, he was not like that. Two trips to the hospital because they messed up by removing the fall pads. His bed is now low, alarm is there. She noted that, instead of putting out an alarm mat, the facility stacked an alarm mat on top of a thicker, cushioned, beveled fall mat, that combined, presented another tripping hazard. Residents Affected - Some In an interview on 1/10/22 at 06:40 PM, Administrator (ADMIN) stated that he did agree that the stacked fall mats could have presented an additional fall hazard to the resident. The Director of Nursing (DON) wasn't sure if we should be stacking the mats. We'll look for the manufacturer's instructions. In an interview on 1/11/2022 at 9:30 AM, with concurrent review of photos of the stacked mats, Director of Staff Development (DSD) stated, That's an additional fall hazard. There is no need to stack the mats. They're both cushioned, and that stacking them would make a fall more likely. In an interview on 1/11/22 at 9:45 AM, DON stated, Ordinarily I don't put two pads together one on top of another. When we put them there we didn't see how it could be a trip hazard. In an interview on 1/18/22 2:30 PM, customer support representative for manufacturer of fall matt, noted that the instructions for use for the alarm and pad specifically stated, WARNING: The manufacturer does not claim that this device will stop elopement and falls. The device is designed to augment caregivers' comprehensive mobility management program . he stated further, We have two types of fall mats, a thicker one that is beveled and has more cushioning, and a thinner one that just has an alarm and less cushioning. We would recommend going with the our thicker, 'weight sensing and landing mat, beveled' rather than stacking the thinner alarm mat with a thicker beveled mat. Stacking those two mats causes an additional tripping hazard because they are both the same size but the lower one is beveled, so the top mat projects over the inner edge of the bevel and the edge could catch a foot. It's not only a danger to patients but to staff who are working with them as well. So stacking them would actually become a trip hazard rather than protection. We would advise against doing that. 3) A review of a facility policy titled, Proper Use of Bed Rails revised 11/2017, indicated the facility would ensure that the use of bed rails are appropriate and safe for the resident, and that bed rails are properly installed and maintained. It indicated the facility will perform an assessment to determine whether to use bed rails to meet the resident's needs and should regularly check positioning or movement that may contribute to possible entrapment every shift. Resident 19 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance and schizophrenia (disorganized speech and thought process). Resident 19 did not have the capacity for making decisions, giving informed consent, or understanding choices to make health care decisions. A review of a physician order dated 07/28/2021, indicated Bilateral side rails at head of bed for mobility. A review of MDS dated [DATE], indicated she had an impaired cognition (unable to think and reason) and required extensive assistance and two person assist with bed mobility and transfers. Review of the care plan dated 8/23/2021, indicated the resident was at risk for falls related to confusion; incontinence; unaware of safety needs; and wandering. It indicated the resident required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 4 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0689 Level of Harm - Minimal harm or potential for actual harm assistance with mobility and activities of daily living. Interventions for the care plan included the use of Bilateral 1/4 side rails to increase mobility and independence (initiated 08/23/2021). The care plan indicated the resident will be provided with the safe use of side rails daily. Interventions implemented by nursing staff included: Residents Affected - Some a. Assessment for entrapment risk between mattress and rail (initiated on 08/29/2021.) b. If side rails are not used or they inhibit resident's freedom of movement the bed rails should be discontinued (initiated 08/29/2021.) During an observation on 01/10/2022 from 12:11 PM to 12:28 PM, Resident 19 was hunched over her bed table and sleeping in bed, with both side rails positioned down beside resident's torso and abdomen. Resident 19's right arm was entrapped in between the bed rails on the right side of the bed, and were not positioned up at the head of the bed as indicated in the physician orders. In a concurrent interview, on 01/10/2022 at 12:34 PM, LN N acknowledged Resident 19 had her right arm caught between the bed rail on the right side of the bed. LN N was observed to awaken Resident 19, she repositioned which freed the resident's right arm from bed rail. LN N placed the bed rails up at the head of the bed as per plan of care. During a concurrent observatio and interview on 01/12/2022 at 2:09 PM, DON stated a bed rail assessment needed to be done on admission, quarterly, or change of condition. DON stated there must be a physician order and informed consent(s) for the resident for the use of bed rails. DON demonstrated the use of bed rails positioned up at the head of the bed versus down beside the resident. DON stated bed rails could become a restraint if positioned down, and would keep the resident in place restricting their movement, and no longer be an assistive device for mobility. DON stated licensed nurses Have the competency to assess the need for bed rails, and the CNA's Don't have the ability to use or implement bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 5 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D was competent to provide safety measures during resident care, when Resident 7 rolled off the bed. This failure resulted in Resident 7 sustaining injuries that required a trip to emergency department services for evaluation and treatment. Findings: A review of Resident 7's record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. The Minimum Data Set (resident assessment), dated 10/10/2021, indicated Resident 7 had severe cognitive impairment 9unable to think or reason), total dependence for activities of daily living (ADLs), and required two person assistance for bed mobility, transfers and toilet care. Resident 7's range of motion was impaired on both sides of her upper and lower extremities, and used a wheelchair for mobility. A review of Resident 7's Interdisciplinary Team (IDT, a team of health care professionals who assess, coordinate, and manage each resident's care) Progress Note, dated 10/25/2021, indicated Resident 7 had a witnessed fall from bed on 10/22/2021 at 5:20 AM, during incontinence care by one staff. Resident 7 had rolled off her bed and sustained skin tears to her left arm. Resident 7 was noted to have discoloration to left side of face. Resident 7 was sent to the hospital emergency department for evaluation, and returned to the facility. Root cause analysis indicated Resident 7 was totally dependent for care, and was two person assist at the time of the accident. Staff did not follow facility policy/procedure for two person assist. Resident 7's care plan was updated with new intervention: re-educate the staff on having two staff in the room, one on each side of the bed during care. During an interview on 1/12/2022 at 5:58 PM, CNA D stated she was assigned care for Resident 7 on 10/22/2021. CNA D stated she was making her final resident rounds on night shift, and decided to change Resident 7, as the resident was incontinent (having no or insufficient voluntary control over urination or defecation). She stated when she rolled the resident towards her on the bed, the resident was too close to the edge of the bed, and Resident 7 rolled onto the floor. CNA D stated Resident 7 was sent to the hospital emergency department for evaluation. CNA D stated that at the time of the incident, Resident 7 was one person assist for incontinence care, and did not require two staff to change the resident. CNA D stated Resident 7 was two person assist for transfers, using a resident lift. She stated the nurse was busy at the time giving medications to another resident. CNA D stated staff education was provided following the incident on use of the resident lift, as well as instruction to always use two staff at all times, when providing care to Resident 7. During an interview on 1/13/2022 at 6:25 AM, Licensed Nurse (LN) F stated she was the nurse on duty on 10/22/2021 when Resident 7 rolled out of bed. LN F stated CNA D was changing the resident at the time of the incident. LN F stated that CNA D was working with Resident 7 by herself at the time of the incident, and reported the incident to her right away. LN F stated Resident 7 was total care and non-verbal. LN F stated that following the incident, education was provided to CNA staff to always have two staff present when providing care to Resident 7, and to use a resident lift. A review of the facility's policy/procedure titled, Safe Resident Handling and Movement, revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 6 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0726 Level of Harm - Minimal harm or potential for actual harm 11/2012, indicated daily staff assignments would include a buddy for assistance when moving or repositioning a resident. If a buddy was not available, another staff would be requested to assist with the resident. DSD was responsible to ensure staff completed initial and annual training, including required training when staff were non-compliant with safe resident handling and movement. Verification of training would be documented in individual staff records. Residents Affected - Few A review of the Human Resources (HR) file of CNA D, indicated that CNA D was hired on 8/18/2020 and completed orientation on 10/22/2020. CNA D's Employee Orientation Checklist, signed 10/22/2020, indicated CNA D had received training on basic resident care. A document titled Buddy System, signed by CNA D on 10/22/2020, indicated This is a Buddy System facility. The Buddy System is a procedure in which two people, operate together as a single unit so that they are able to help each other. The Buddy System is a great way to improve safety. When in doubt ALWAYS remember to ask for help. The following documents (checklists) were not in CNA D's HR file: CNA Core Clinical Competencies, Mechanical Lift (Sling Lift), and Turning and Positioning a Resident. During a concurrent observation, interview and document review on 1/13/2022 at 9:30 AM, with Director of Staff Development (DSD) stated she used a human dummy to train nursing staff how to turn and reposition residents. DSD stated CNA competencies were validated upon hire during orientation, and annually as part of the performance evaluation process. DSD provided a packet of documents (checklists) including CNA Core Clinical Competencies, Mechanical Lift (Sling Lift), and Turning and Positioning a Resident, which DSD stated were used for validating staff competency. DSD was unable to provide copies of these documents completed for CNA D. DSD stated the requested documents could be in CNA D's Human Resource file. When asked for a copy of the facility's policy and procedure for staff competency evaluation, DSD stated the facility did not have a policy, and would follow regulatory standards. A review of the facility's competency checklist titled, Turning and Positioning a Resident, not dated, indicated when resident cannot assist two CNAs perform this procedure on opposite sides of bed. A review of the Facility Annual Assessment, dated 3/21/2021, indicated each nursing staff member would have nursing competency skills reviewed upon hire and annually thereafter. The DSD was responsible for monitoring compliance. A review of the facility's Job Description - Certified Nursing Assistant, dated 2003, indicated the CNA would perform all assigned duties in accordance with established policies and procedures, and as instructed by supervisors. During a concurrent interview and record review on 1/13/2022 at 1:36 PM, Director of Nursing (DON) stated the incident happened because CNA D had not followed the facility's standard of practice for two staff members present, one on either side of the bed, when positioning totally dependent residents. DON stated that Resident 7 was totally dependent, and had been for several years prior to the incident. When asked about education provided to staff as a result of the incident, DON confirmed there was no documentation regarding education or training of staff following the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 7 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on dietetic services observations, dietary staff interview and departmental document review, the Registered Dietitian (RD) and/or the Dietary Services Supervisor (DSS) failed to ensure: Residents Affected - Many 1) Vegetarian menus were in place and followed. 2) Timely and effective communication and monitoring system was in place between the facility kitchen and the contract kitchen regarding resident diet orders and food allergies. These failures had the potential to result in nutritionally inadequate meals, and the potential to promote decline in medical and nutritional status as well as quality of life for residents who received food from the facility food services. Findings: 1) During concurrent observations, interviews and record reviews between 01/10/22 at 9:15 AM and 1/13/22 at 4 PM showed: a vegetarian menu was not used or followed. Menus were not followed for mechanical soft diets; Portions were not served according to the menu; and menus for therapeutic diets were not followed (Cross Reference F803). 1A) A menu was not followed for Vegetarian Diets. During an observation of the lunch meal tray line on 1/11/22 between 11:45 and 12:15 PM, two residents (14 and 42) had vegetarian diet orders and were served entrée salads (Cross Reference F803). During an interview with [NAME] O (CK) O in the contract kitchen on 1/11/22 at 10 AM, she stated there was no set menu for vegetarian diets, staff switch it up every day. During a concurrent interview and record review with the contract kitchen FNSD on 1/11/22 at 10:50 AM, he stated he leaves it up to the cooks to decide what to make for the vegetarian options each day. He further stated he had ability to print out a vegetarian menu if residents/families wanted it. The vegetarian menu was not posted in the facility kitchen, the contract kitchen, or the cook's binder for staff reference. A review of the vegetarian menu provided by the FNSD showed vegetarian foods served on 1/10/22 and 1/11/22 did not match the vegetarian alternate foods listed on the menu (Cross Reference F803). During an interview with the RD on 1/13/22 at 9:19 AM, she stated the vegetarian menu should be the same as the regular menu but with a meat replacement. She stated she didn't have access to the vegetarian recipes and agreed she didn't have vegetarian on her menu spreadsheets. During a telephone interview with the contract kitchen FNSD on 1/13/22 at 12:15 PM, he stated he didn't have any of the vegetarian recipes listed on the menu. 2) During a review of resident tray tickets on 1/11/22 at 8:09 AM, food allergies for two residents (36 and 397) were noted. Resident 36 had an allergy to walnuts, and Resident 397 had an allergy to peanuts and buckwheat. During an interview with the contract kitchen FNSD on 1/11/22 at 10:31 AM, he stated he got the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 8 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many allergy list from the facility DSS. Facility dietary staff called the contract kitchen and reported food allergies to them. They do not provide resident's names or room numbers, just the list of the food allergies. During an interview regarding food allergies on 1/11/22 at 2:29 PM, the DSS stated she called the contract kitchen to report allergies and provided them with a paper copy diet count weekly. On 1/12/22 at 3:40 PM, the DSS stated she sent the allergy report to the contract kitchen with each meal count report. During an observation on 1/11/22 at 02:40 PM, in the contract kitchen, the meal count report was on a clipboard. It was undated and showed no food allergies. During a concurrent interview, the FNSD agreed there was no date on the form to know when it was received. He stated the DSS emailed it to him, and there was lots of verbal communication between the contract kitchen and facility kitchen, and his staff wrote any changes on the (meal) counts. He stated he couldn't remember there being any food allergies in the past few months. During a telephone interview with the RD on 01/13/22 at 9:18 AM, she stated food allergies should be communicated to the contract kitchen immediately. During an email conversation and concurrent document review with the FNSD on 1/13/22 at 9:07 AM, he provided what he identified as his last 2 resident meal counts provided by the facility kitchen: Diet Count 10-26 and Diet Count 12-29-21. No food allergies were listed. The FNSD stated he no longer had the original emails from the DSS (to see if food allergies were provided there). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 9 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure contracted kitchen staff were able to verbalize or demonstrate their competence to carry out the responsibilities of the food and nutrition services when: 1) Staff did not properly complete the food cooling process to ensure food safety. 2) Staff signed off on cleaning schedules, indicating 100% of daily cleaning assignments were completed when equipment was not clean. 3) Staff did not follow standardized recipes. These failures had the potential to result in foodborne illness, decreased nutritional status, and medical decline for residents consuming food prepared in the contract kitchen. Findings: During observations and concurrent interviews with the contract kitchens' Food and Nutrition Services Director (FNSD) and staff between 1/10/2022 at 9:45 AM and 1/12/2022 at 4 PM staff knowledge and professional standards of practice were not consistently in place. Temperatures were not monitored or documented for food stored in the sandwich station. Expired food was not discarded. Food was not properly labeled and dated. Raw animal protein was not labeled, dated, or stored correctly. Cool down logs were not completed for tuna or egg salad. Staff did not follow standardized recipes and pureed food did not meet the required consistency. (Cross Reference F803, F805, F812). 1). During an observation in the contract kitchen on 1/11/22 at 10:00 AM [NAME] O (CK) stated she had been at the facility for about 4 years. She prepared egg salad using pre-cooked eggs, then placed it in a refrigerator. A cooling log was started with a 10 AM start time and initial temperature 49°F. During an observation, concurrent record review and interview in the contract kitchen on 1/11/22 at 3:10 PM, the cooling log on the refrigerator showed no further temperature monitoring had occurred for Tuna Salad or Egg Salad since the log was started at 10 AM. The FNSD stated his expectation was staff should have checked the temperatures again at 12 noon and 2 PM. Review of a document titled, Inservice a2021, provided by the FNSD, indicated he provided an in-service on cooling and reheating food to his staff on 10/22/21 but CK O's name was not on his typed list. During a telephone interview on 1/13/22 at 12:15 PM, FNSD stated he did not have sign in sheets, curriculum, posttests, training checklists or competencies available for his staff. 2). During observations of the contract kitchen between 1/10/2022 at 9:45 AM and 1/12/22 at 4 PM it was not sanitary. (Cross Reference F812). Review of contract facility documents titled, Cleaning Schedule and Check List Dish/Prep and Cleaning Schedule and Check List Cooks dated weekly from 12/13/21 through 1/9/22 showed 100% of daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 10 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaning assignment were signed off as completed. The daily cleaning assignments for both AM and PM shifts included cleaning carts, pot and pan shelves, the walk-in refrigerator and freezer. Review of a policy titled, Sanitation dated 2018 showed, The FNS Director is responsible for instructing Food & Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area. During an observation and concurrent interview on 1/11/22 at 2:40 PM, CK K stated she was responsible for shutting down the kitchen and ensuring it was clean at the end of the night. She described the process as washing the counters with soapy water; wiping off the soap; then wiping with sanitizer. CK K re-confirmed she used 2 steps -detergent and then sanitizer to clean the counters. Review of a policy titled, Shelves, Counters and Other Surfaces Including Hand Washing Sinks, dated 2018, showed the cleaning procedure includes 3 - steps as the following: * Washing surface with a warm detergent solution following manufactures instructions . * Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. * Spray with a sanitizer Review of a document titled, Inservice a2021 provided by the FNSD indicated he provided an in-service titled Demonstrate Sanitizer on 09/25/21 and Understanding Cleaning List on 11/24/21. CK K's name was typed in as present at both in-services. During a telephone interview on 1/13/22 at 12:15 PM, FNSD stated he did not have sign in sheets, curriculum, posttests, training checklists or competencies available for his staff. 3). During an observation of lunch tray line (meal tray assembly process) in the facility kitchen on 1/11/22 at 12:15 PM, Resident 24's tray ticket indicated a 2-gram (2gm) sodium diet order and he was given regular polenta. There was no low sodium version of polenta available. Review of a document titled, Winter Menus, Cooks Spreadsheet dated 1/11/22 showed 2gm sodium diets were to be served polenta no parmesan (cheese). During an interview with the contract kitchen's Food and Nutrition Services Director (FNSD) on 1/11/22 at 2:40 PM, he stated staff should have removed a portion of the polenta to not have parmesan. During an observation and concurrent interview in the contract kitchen on 1/11/22 at 10 AM near the recipe binders CK O was asked, How do you follow recipes when the recipe binders are here (near FNSD office) and you cook on the other side of the room? CK O stated she memorized the recipe and used pork gravy to make the sauce. Review of a document titled, Recipe: Pork in [NAME] Sauce dated Week 2 Tuesday showed, Low-sodium beef broth was to be used. Pork gravy was not listed. The recipe noted SPECIAL DIETS: 2 GM NA (sodium)/LOW SALT: May give, sauce is made with low-sodium beef broth. During an observation of lunch tray line on 1/11/22 at 12:15 PM, Resident 14's tray ticket showed he had a Vegetarian diet order, and he was served a salad of romaine lettuce topped with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 11 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0802 approximately 1/4 cup beans on an entrée-sized plate. Staff called it a Veggie Salad. Level of Harm - Minimal harm or potential for actual harm Review of an undated recipe titled, Recipe: Vegetarian Chef's Salad, provided by the FNSD specified the salad should contain a combination of lettuces, cheese, tomatoes, hard-cooked eggs, and salad dressing with optional sliced beets, shredded carrots, alfalfa sprouts. The salad provided contained lettuce with approximately ¼ cup of beans. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 12 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 1. During an interview with Dietary Aide (DA) L on 1/10/22 at 11:30 AM, she stated they currently had 2 Vegetarian residents in the facility. One vegetarian resident (Resident 42) sometimes wanted meat because she got tired of salads. During an interview with Resident 14 on 1/10/22 at 12:01 PM, he stated he was vegetarian, ate dairy, eggs and fish, but he did not receive enough vegetables. He stated no dietitian had discussed his diet with him. He wanted nuts but received no nuts. During an observation of lunch tray line and concurrent record review of lunch tray tickets, on 1/10/22 between 11:30 AM and 12:30 PM, Resident 14's tray ticket showed a Vegetarian diet order, and Resident 42's tray ticket showed Lacto-Ovo Vegetarian (includes dairy foods and eggs) diet order. Resident 42 was served noodles, tofu steak, mixed vegetables, and corn soup. During an observation of the lunch meal tray line on 1/11/22 between 11:45 AM and 12:15 PM, 2 Vegetarian residents (14, 42) were served entree salads. Resident 14's salad was romaine lettuce with approximately 1/4 cup garbanzo beans on top, no other visible ingredients visible. In a concurrent interview the Dietary Services Supervisor (DSS), stated Resident 14 should receive the vegetarian bean soup in addition to his salad. A #8 scoop (1/2 cup) portion of bean soup was served in a bowl. Review of an undated document titled, Recipe: Navy Bean Soup showed portion size was 1 cup and equaled 1 ounce of protein. During an observation and concurrent interview in the contract kitchen on 1/11/22 at 10 AM, a binder labeled Vegetarian Menus and Recipes was reviewed in the presence of CK O. When asked how the cooks knew what to cook for vegetarian residents CK O stated there was no set menu. We just switch it up every day. When asked how a cook would know what was served to vegetarian residents on previous days, she stated, Someone always knows what the person before us did. Since the facilities did not follow the vegetarian menu and staff served what they wanted, this resulted in a potentially low nutrient meal. During an interview with the contract kitchen Food & Nutrition Service Director (FNSD) on 1/11/22 at 10:50 AM, he stated for vegetarian options they have their Vegetarian binder. They carry vegetarian sausage and vegetarian patties. Recently they've had more vegetarian residents, but they come in spurts. He stated he leaves it up to the cooks to decide what to make for the vegetarian options each day. Current vegetarians like a lot of salads. If a resident or family wanted to see a defined menu he could print up a vegetarian menu from the menu vendor. He stated the current vegetarians were happy with the food and how it was served. Review of a document provided by the FNSD titled, Good For Your Health Menus Vegetarian Menu dated Winter, Week 2, January 10-16, 2022 showed lacto-ovo (contains dairy/eggs) vegetarian breakfasts and lunch and dinner alternate vegetarian choices. This menu was not present in the Vegetarian Menus and Recipes binder and it was not posted in the Contract Kitchen or Facility Kitchen for staff use. On 1/10/22 the normal menu showed Sesame Orange Chicken, Chinese Corn Soup and Imperial Noodles, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 13 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with Vegetarian Alternates listed as Vegetarian Chinese Corn Soup and English Muffin Cheese Pizza. The vegetarian alternate foods actually served were grilled tofu/no sauce, and regular corn soup. On 1/11/22 the normal menu showed Pork in [NAME] Sauce and Polenta, with the Vegetarian Alternates listed as Grilled Tofu with Cacciatore Sauce and Vegetarian Polenta. The vegetarian alternate foods actually served were bean soup and a lettuce salad with garbanzo beans. An email to the Contract Kitchen FNSD on 1/13/22 at 10:32 AM requested vegetarian recipes listed on the facility's Good For Your Health Menus Vegetarian Menu dated Winter, Week 2, January 10-16, 2022 on 1/10/2022, 1/11/2022 and 1/12/2022. During a telephone interview with the contract kitchen FNSD on 1/13/22 12:15 PM, he stated he didn't have any of the vegetarian recipes listed on the menu. Review of an undated document in the Vegetarian Menus and Recipes, binder titled Spreadsheet for Vegetarian, guided staff to follow recipes and replace the MEAT entrée of the day with the vegetarian entrée. Review of an additional undated document titled, Nutritional Breakdown for Vegetarian for RDs, listed the nutritional value of the diet as Calories 2000, Protein 75-80 grams, Fat 90 grams, Carbohydrate 229 grams. The contract and facility kitchens did not follow the vegetarian menu alternates or recipes, so the nutrient content of meals provided to vegetarian residents was unknown. Review of the Minimum Data Set (MDS- resident assessment) indicated, Resident 14 was admitted to the facility on [DATE] and Resident 42 was admitted to the facility on [DATE]. This indicates that potentially 78 out of 78 meals (3 meals per day multiplied by number of days living in the facility) served to Resident 14 since his admission to the facility, and potentially 519 out of 519 meals served to Resident 42 since her admission to the facility did not provide a nutritionally adequate vegetarian diet. During a telephone interview with the RD on 1/13/22 at 9:18 AM, she stated the vegetarian menu should be the same as the regular menu but with a meat replacement. She stated I don't have access to the recipes. She acknowledged she didn't have vegetarian on her menu spreadsheets and stated the spreadsheet says Follow the Vegetarian Substitute for vegetarians. Review of documents titled, Winter Menus Cooks Spreadsheet, dated 1/10/22, 1/11/22 and 1/12/22 showed no vegetarian diet was listed. A review of the facility's policy of Menu Planning, dated 2018, indicated: a. The menus are planned to meet nutritional needs of residents in accordance with established national guideline, physician's orders . b. Food & Nutrition Service Director (FNSD) shall keep a copy of the menu as served on file at least 30 days c. Standardized recipes adjusted to appropriate yield shall be maintained and used food preparation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 14 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During an observation of the lunch meal service on 1/11/22 at 12:15 pm, Dietary Aide (DA) P placed fresh, un-chopped parsley on the trays for mechanical soft diets. Review of a document titled, Winter Menus, Cooks Spreadsheet, dated 1/11/22 indicated mechanical soft, pureed and dysphagia mechanical diets were to be garnished with parsley flakes (small and thin pieces). No parsley flakes were observed present on tray line. Regular texture garnishes such as whole fresh parsley had the potential to be a choking hazard for residents on a texture modified diet. Modifed texture garnishes such as parsley flakes are not a choking hazard and can create an appetizing color contrast in the presentation of resident meals. Review of resident meal tray tickets dated 1/12/22 showed 10 residents with mechanical soft diet orders (Residents 3, 17, 18, 28, 30, 34, 245, 251, 254, 397). During an interview on 1/10/22 at 10:30 AM, the contract kitchen FNSD stated the facility kitchen received separate deliveries for dry goods (this would include parsley flakes) and those goods were stored at that facility. Ingredients to prepare food were delivered and stored at the contract kitchen. During an interview with DA L in the facility kitchen on 1/12/22 at 7:40 AM, she was asked about use of parsley flakes for garnish. She stated they didn't stock garnishes there (at the facility kitchen). The garnishes would need to come from the contract kitchen. 3. During an observation of lunch tray line (meal assembly process) and concurrent review of lunch tray tickets on 1/10/2022 between 11:50 AM and 12:15 PM, Dietary Aide M (DA M) served vegetables using a gray handled portion scoop (#8, 1/2 cup). Residents (4 and 397) were served approximately half scoops of vegetables. Review of lunch tray tickets showed Resident 397 had a regular, mechanical soft diet order and Resident 4 had a regular diet order. Neither resident had small portions ordered. Review of a document titled Winter Menus, Cooks Spreadsheet dated 1/10/22 showed the serving size for Golden Carrots&Zucchini with Margarine for regular and mechanical soft diets was 1/2 cup. During an observation of lunch tray line on 1/11/22 at 12:15 PM Resident 38 received a regular portion of polenta when the diet order on her tray ticket showed small portions. During an observation of the lunch tray line, on 1/11/22 at 12:15 pm, DA P used a #12 (1/3 cup) green scoop for the small portions of polenta. Review of a document titled Winter Menus, Cooks Spreadsheet dated 1/11/22 indicated a #16 (1/4 cup) Blue scoop should be used for the small portions of polenta. A review of the facility's policy titled, Food Preparation - portion control, dated 2018, indicated To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used .; Scoops are sized by number . the smaller the number, the larger the size . 4. Review of a document titled, Winter Menus, Cooks Spreadsheet dated 1/11/22 showed the 2gm sodium diet was to be served polenta -no parmesan (cheese) and salt free salad dressing. It also showed a low fat/low cholesterol diet order should be served fat free salad dressing. During an observation of lunch tray line in the facility kitchen on 1/11/22 at 12:15 PM, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 15 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 24's and 28 tray ticket indicated a 2-gram (2gm) sodium diet order. He was given regular polenta (included parmesan) and regular ranch salad dressing (not salt free). Resident 22's tray ticket indicated he had a consistent carbohydrate, low fat/ low cholesterol diet order and he received regular salad dressing (not low fat). Resident During an interview with the contract kitchen's FNSD on 1/11/22 at 2:40 PM, he was asked about 2 gm sodium diet orders. The menu spreadsheet for 2 gm low sodium polenta stated no parmesan. FNSD confirmed kitchen staff should have prepared a low sodium polenta without parmesan to serve residents with low sodium diets. Based on observation, interview and record review, the facility failed to ensure menus were in place and followed when: 1. A vegetarian menu was not used or followed, and the nutritional adequacy of vegetarian meals served to two residents (Residents 14, 42) since admission was unknown. 2. Menus were not followed for 10 of 10 residents (Residents 3, 17, 18, 28, 30, 34, 245, 251, 254, 397) on mechanical soft diets. 3. Portions were not served according to the menu for six of 43 residents (Residents 4, 10, 12, 19, 38 and 397). 4. Menus for therapeutic diets were not followed for three residents (Residents 22, 24 and 28). These failures created the potential for residents to receive food that did not comply with the physician ordered diet, did not meet resident nutritional needs, and had the potential to compromise residents' medical status, nutritional status, and quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 16 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on resident interviews, meal delivery observations and departmental document review the facility failed to ensure meals were presented at a temperature that met the individual preferences of two Residents (Residents 36 and 246). Failure to ensure meals are prepared and delivered in a manner that meets residents needs may result in decreased food intake, resulting in weight loss further compromising medical status. Residents Affected - Many Findings: During an interview on 1/10/2022 at 9:30 AM, Resident 246 stated Breakfast is always cold. During an interview on 01/10/22 at 12:05 PM, Resident 36 stated Food is sometimes cold, they need some plate warmers or something . Eggs and toast are not hot. I think I'm the last of the line. The toast is ice cold. On 01/12/22 beginning at 8:05 AM, a test tray was conducted on Unit B. The cart contained 11 resident trays in addition to the test trays. It was noted Unit B was designated as a COVID-19 yellow zone. The COVID-19 yellow zone is intended for residents who are awaiting COVID-19 test results or may have been exposed to someone who has tested positive. Standards of practice require gown and gloves are worn and changed between Residents. In an interview on 1/12/22 at 8:20 AM, the Dietary Services Supervisor (DSS) stated the necessity for nursing staff to change gowns and gloves prior to entering the room of each resident increased the amount of time required for meal distribution. The DSS also stated they used to have a heated base warmer however that piece of equipment was broken and was not replaced. She also indicated there were no modifications to the meal distribution process to account for additional time required for meal delivery. Food temperatures were taken on 01/12/22 at 8:29 AM, after the 11 resident trays were distributed and all residents were eating. The temperatures were recorded using the facility thermometer: French toast 95°F (degrees Fahrenheit - a unit of measure); sausage 106°F; pureed sausage 98°F and pureed French Toast 108°F. In a concurrent interview the DSS acknowledged the hot foods were not warm enough. With respect to the pureed French toast, she would like to taste more cinnamon. Departmental document titled Meal Service dated 2018 indicated the recommended food temperature of hot items, including French toast was 120°F or greater. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 17 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on dietetic services observations, dietary staff interview and departmental document review the facility failed to ensure pureed foods for seven residents (Residents 7, 8, 32, 40, 252, 244 and 396) were prepared in accordance with standards of practice and departmental policies. Failure to ensure meal preparations were in accordance departmental procedures may result in decreased meal intake compromising the nutritional status of residents. Findings: The International Dysphagia Diet Standardization Initiative describes a pureed diet as one where all food should be pureed to a homogenous, cohesive, smooth texture. Foods should be pudding-like and hold its shape on a spoon. Contains no lumps. Not sticky. Pureed foods can be piped or molded and will not spread out if spilled. The prongs of a fork make a clear pattern when drawn across the surface of the puree. During meal plating observation on 1/11/22 beginning at 11:20 AM, it was noted the pureed broccoli resembled a thickened creamed soup. It was noted when it was plated it did not hold shape, rather spread out on the plate. In a follow up observation on 1/12/22 at 8:05 AM, it was noted the pureed sausage also did not hold it's shaped, rather resembled a thickened creamed soup. In a telephone interview on 01/13/22 at 9:18 AM, the Registered Dietitian (RD) indicated she reviewed the operations of the contract food service. The RD also indicated there were frequent calls to the contract food service which included concerns regarding food consistency, giving an example that pureed foods are thin. Additionally, the RD indicated she provided the supervisor of the contracted food service with a written report outlining the areas of concern. Review of facility document titled Consultant Dietitian Report Card dated December 2021 indicated therapeutic and texture modified diets were not accurately served, however there was no description of what the issue was. Additional reports dated June through July 2021 indicated there were no issues with texture modified diets. The description of the regular pureed diet from the facility diet manual dated 2020 confirmed pureed food items should be of a smooth moist consistency and able to hold its shape. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 18 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food were stored, prepared, distributed and maintained in safe and sanitary condition in their contracted kitchen when: 1. a. The facility kitchen staff were not following the departmental dress code. b. Internal bin of the ice machine had an area with pink, clear slimy appearing material. c. The kitchen areas and equipment were not clean. 2. a. Refrigerated food were not labeled, dated, monitored and raw foods were not separated from ready-to-eat foods. b. Potentially hazardous foods (PHF) were not at safe temperatures below 41°F. These failures had the potential for the spread of infection and foodborne illness to occur to residents. Findings: 1. a. On 1/10/2022 at 9:15 AM, during the initial tour of the facility contract kitchen and concurrent interviews with Dietary Aide (DA) L and DA M, the following were observed: * DA L and DA M wore no apron. * DA M did not wear a hair net or hat. DA M's forehead was sweating and he wiped the sweat with his sleeve. * At 9:52 AM, during a concurrent observation and interview with Food & Nutrition Service Director (FNSD), kitchen staff were observed to have no apron on, and FNSD's shirt front was covered with white powder and food debris. During a concurrent observation and interview, in the contract kitchen, on 1/11/2022 at 2:40 PM, [NAME] (CK) K was wearing a soiled apron. A review of the facility policy titled, Food Borne Illness Outbreak, dated 2018, indicated Poor Personal Hygiene - examples: . wearing soiled aprons . An undated document titled, Personal Hygiene, posted in the facility's kitchen indicated proper attire included wearing an apron. A review of the facility policy titled, Dress Code, dated 2018, indicated the proper dress for men with short hair was to wear hats and for the men with long hair (over the ears of longer) was to wear a hair net. In an interview on 1/12/22 beginning at 9:30 AM, the Dietary Service Supervisor (DSS) indicated it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 19 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0812 was the expectation that the contracted kitchen follows the policies and procedures adopted by the facility. Level of Harm - Minimal harm or potential for actual harm b. During an observation of the ice machine and concurrent interview with the Maintenance Director (MAINT) on 1/10/2022 at 2:57 PM, the internal bin of the ice machine had an area with pink, clear slimy appearing material on the ice deflector (a temporary shield from frost damage). MAINT stated, That means it's time to clean the ice machine. A Review of the ice machine cleaning log, indicated the last date of cleaning the ice machine was on 12/10/2021. MAINT stated he didn't know what the pink stuff was, and he cleaned the inside of the ice bin with vinegar and water. Residents Affected - Many A review of the facility policy titled, Ice Machine Cleaning Procedure, dated 2018, indicated The ice machine (bin and internal components), needs to be cleaned monthly and the date recorded when cleaned .Information about the operation, cleaning and care of the ice machine can be obtained from owner's manual . A review of the ice machine manufacture's instruction manual titled, Manitowoc INDIGO NXT Air/Water/Remote Condenser Ice Machines - Technician's Handbook, revised 5/2019, indicated: * Use only Manitowoc approved Ice Machine Cleaner and Sanitizer for cleaning/sanitizing procedure. * Ice Machine cleaner is used to remove lime scale and mineral deposits. Ice Machine sanitizer disinfects and removes algae and slime. * The manual did not direct use of vinegar and water to clean or sanitize the ice machine. c. On 1/10/2022 at 9:15 AM, during the initial tour of the facility contract kitchen , the can opener and mount were observed soiled with grime and debris. FNSD stated, It's soiled. It's supposed to be cleaned each night. Cook's Prep Sink Area observation: * A cart next to the cook's prep sink was observed to have soiled, unclean trays, stained blender pitchers and lids, and old food debris on the bottom shelf. *The wall and ceiling had splatters of food debris. * There were three expired food items on the condiment cart: white vinegar, expired on 11/9/2021; [NAME] wine, expired on 1/3/2022; cooking wine, expired on 2/15/2021. FNSD stated those should be thrown away. * Drips around lid and down the side of Worcestershire Sauce. * A visible soiled large freestanding mixer with a hair and food debris on it. * The meal delivery cart for the facility was soiled with grease stains. Seven cutting boards were observed to be worn and had deep cut grooves. FNSD indicated he had replacements in his office, however did not recall the last time he replaced the cutting boards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 20 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of the facility policy titled, Can Opener and Base Clean Procedure, dated 2018, indicated Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation 1. The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. A review of the facility policy titled, Sanitation, dated 2018, indicated .9. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks . A review of the contract kitchen's dish/prep cleaning logs and cook cleaning logs from 12/13/21 to 1/9/2022, indicated, can open, blender, back wall, mixer . need to be cleaned every shift; floors, carts, shelves, walk-in refrigerator, freezer . need to be clean at least every shift; walls need to be cleaned in March and September. Staff signed off both assignments indicating cleaning was completed. During a concurrent observation of the walk-in refrigerator and freezer and interview with FNSD on 1/11/2022 at 10:11 AM, the door and the gasket crevices were soiled with a black substance resembling mold. The floor of the walk-in freezer was soiled. FNSD stated it needs to be cleaned. FNSD agreed that the black substance shouldn't be there, and the staff should made sure it was clean. A review of the facility policy titled, Procedure for Refrigerated Storage, dated 2018, indicated #3. Refrigeration equipment should be routinely cleaned. A review of the facility policy titled, Refrigerator and Freezer, dated 2018, indicated: 1).Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods . 2). Refrigerator and freezer should be on a weekly cleaning schedule. 3). Frequently clean the refrigerator and freezer handles, since they are touched countless time a day. 4). Wipe down gaskets with soapy water. A review of documents titled, Dish/Prep Cleaning Schedule and Check List dated 12/13/21 though 12/19/21, 12/20/21 through 12/26/21 and 12/27/21 through 1/2/22 showed Walk-in and Freezer were assigned to be cleaned daily. Staff signed off both assignments indicating cleaning was completed 21 out of 21 opportunities. The standard of practice would be to ensure cleaning frequency of equipment food contact surfaces are clean to slight and touch at all times (USDA Food Code, 2017). 2. a. During an observation of the facility Unit B kitchen refrigerator on 1/10/2022 at 3:25 PM : * A carton of Med Pass 2.0 vanilla (liquid nutritional supplement), was opened without opened date. * A carton of Med Pass 2.0, Reduced Sugar, Vanilla was opened without opened date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 21 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0812 Level of Harm - Minimal harm or potential for actual harm Med Pass 2.0 carton indicated, Storage and Handling- After open, consume product within 4 days if properly refrigerated .within 4 hours if not refrigerated. In an interview on 1/12/22 at 7:40 AM, the DSS stated there was no policy or procedure for the handling of the Med Pass supplement. Residents Affected - Many During an interview on 1/12/11 at 11:30 AM, Licensed Nurse (LN) H stated a new supplement was taken from the refrigerator each morning, and opened. She acknowledged she should have put an opening date on it. A follow up observation on Nursing Unit A, noted the Med Pass supplement was opened, dated, however had no opening time recorded on the carton. An additional observation and concurrent interview on 1/12/22 at 3:15 PM, LN S indicated she usually put the supplement back in the refrigerator if it had been out too long or felt warm. A temperature was taken noted 54 degrees Fahrenheit. During an interview on 1/13/2022 at 9:50 AM, RD stated nursing should have discarded the Med Pass if opened. During an interview on 1/13/22 at 12:10 PM, the Director Of Nursing confirmed he was unable to locate a policy or procedure for the handling of the Med Pass supplement. During an observation in the Walk-in refrigerator on 1/10/2022 at 9:45 AM: * Six 10 lbs chubs of ground beef were fully thawed; three 14 lbs pork butts were fully thawed: both items were unlabeled, no thaw dates or use-by-dates. FNSD stated the ground beef and pork butt roasts came in on the Friday delivery (1/7/2022) and were put straight into the refrigerator to thaw. During a follow-up observation of the walk-in refrigerator and concurrent interview with FNSD on 1/11/2022 at 10:15 AM. There were three 10 lbs thawed chubs of ground beef (left from 1/10/22) with labels, indicating prep on 1/7/22, use by 7 days; a bag of thawed pork butts with labels, indicated prep on 1/7/22, use by 7 days; a bag of thawed chicken with label, indicated prep date:1/10/22, use by 1/15/22. While reviewing an undated document titled Refrigerated storage guideposted on the door of the refrigerator with FNSD, he stated I labeled the date wrong. A review of the vendor' invoice with delivery date 1/7/2022, showed the ground beef and pork butt were delivered fresh, not frozen. *Two plastic bags were dated 1/7/2022, and were not labeled. The contents of one bag resembled cooked sausage. The contents of the second bag resembled sliced cured sausage. FNSD stated they were sausage and pepperoni used in making pizza. * Boxes of bacon were stored above ready-to-eat-foods. A review of the facility policy titled, Procedure for Refrigerated Storage, dated 2018, indicated Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated . A review of the facility policy titled, Refrigerated Storage Guide, dated 2018, indicated that the maximum refrigeration time once meat has thawed for roasts, steaks, chops, poultry, fish and ground meat is 2 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 22 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of the facility policy titled, Proper Refrigerator Storage, posted on the door of the walk-in refrigerator, indicated, all raw foods should be placed under cooked and ready-to-eat food. 2. b. During a concurrent observation of the refrigerated sandwich station and interview with FNSD on 1/10/2022 at 10:45 AM, the station contained deli meat (ham, turkey) and mayonnaise. When temperature was checked: turkey was 48°F, ham was 46°F. mayonnaise was at 48°F. The thermometer in the refrigerator below the sandwich station registered 46°F. FNSD stated the items are filled at the end of the day. Food items may be tossed next morning based on how they look, there is no temperature monitoring of food times. He stated, We should have, but we didn't. FNSD acknowledged that the temperature should be below 41°F. If food was above 41 °F or greater for more than 6 hours, it should be discarded. FNSD also agreed that without proper temperature monitoring system, there would be no way to know when the food was out of temperature. FNSD stated that he reviewed refrigerator temperature logs every Monday but does not validate any temperature. A review of the facility policy titled, Food Borne Illness Outbreak, dated 2018, indicated Unsafe Food Holding Temperatures - examples: holding prepared, potentially hazardous foods at room temperature; unsafe refrigeration temperatures; unsafe hot holding temperatures. A review of the facility policy titled, Procedure for Refrigerated Storage, dated 2018, indicated the refrigerator temperature should be kept at 41 °F or lower. Potentially hazardous foods (PHFs) are those capable of supporting bacterial growth associated with foodborne illness. Protein based foods such as eggs and meat are considered as PHFs and require time/temperature control for food safety. Foods that may be prepared from ingredients above 41 degrees must be cooled to 41 degrees Fahrenheit (°F) within 4 hours of preparation (USDA Food Code, 2017). During an observation and concurrent interview on 1/11/2022 at 10 AM, CK O had just completed making egg salad. She stated the temperature was 49 °F. Upon checking the temperature of egg salad, it showed 52 °F. CK O indicated egg salad was prepared 2 to 3 times per week. During a follow up observation on 1/11/2022 at 3:10 PM, of the cooling process for the egg salad, it was also noted the facility had prepared tuna salad. A label on the tuna salad indicated it was placed inside the refrigerator on 1/11/2022 at 10 AM. A temperature check of the tuna salad was 46°F after being placed inside the refrigerator for 5 hours. Concurrent record review of the cooling log in the presence of the FNSD indicated the cooldown process for the tuna salad was not monitored. Additionally, while the egg salad was listed on the cooling log at 10 AM, no follow up temperatures were recorded. FNSD stated staff should have checked the temperature again at 12 AM and 2 PM. A review of the facility policy titled, Cooling and Reheating Potentially Hazardous Foods (PHF) ., dated 2018, indicated Ambient Temperature Foods: Potentially hazardous foods shall be cooled within 4 hours to 41°F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Used cool down log in section 7, for ambient temperature foods. Review of departmental document titled, Cooldown Log, beginning 10/1/2021 through 1/12/2022, the contract kitchen failed to document any entries for tuna salad. With the exception of the incomplete 1/12/2022 entry for egg salad, there was no other cooldown monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 23 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the Administrator (ADMIN) failed to provide and administer oversight and use its resources effectively when: Residents Affected - Some 1. Infection control program for soiled resident laundry was not implemented, staff training, to ensure their policy and procedures followed Center of Disease Control (CDC) infection control standards. This failure resulted in resident clothing not being clean and sanitary and had the potential to spread disease and infection throughout the facility. Refer to F 880 and F 867 2. Dietary services did not follow national standards and guidelines for kitchen cleanliness, food temperatures,storage and nutritional needs. Refer to F 803, F804, F 805 and F 812. This commulative failures resulted in a potential for spread of disease and infection and dietary needs of residents' not to be met. Findings: A review of the facility's Administrator Job Description, dated 2017, indicated the ADMIN was responsible to Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas and/or improvement of services. Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by governing board. 1. A review of a facility policy titled, Infection Control Manual - Laundry Department date 5/7/2019, indicated It is the policy of this facility to practice safe and sanitary laundry procedures and the purpose of the policy is to decrease the risk of disease transmission . and ensure an effective infection control program. Administrative staff act jointly with the infection control committee to create policies and procedures to laundering resident's personal clothing. Monitor linen handling in resident care and laundry areas to ensure proper procedures are followed. Act jointly with infection control committee in making periodic facility inspection to ensure infection control standards consistently maintained. Soiled linen will be removed from the resident's room and placed in a sealed soiled linen container and kept away from closets. Laundry supervisor will perform set standards for department in accordance with all local, state, federal law and standards (CDC), regulations and guidelines. Implement effective systems for laundry sanitation including regular cleaning and maintenance for all linen areas. Train staff in all policies and procedures pertaining to use of equipment and infection control. In an interview on 01/11/2022 at 11:31 AM, a family member (RP 1) stated I do my husband's laundry because the laundry here sucks. They washed his clothes in the mesh bag without taking it out and I found food stuck on the clothes after they had supposedly been washed. In a concurrent observation and interview, on 01/11/2022 at 2:10 PM, a white mesh bag with dirty laundry belonging to Resident 22 was observed in his closet. Certified Nursing Assistant (CNA) J confirmed the white mesh bag had dirty laundry and stated that laundry services are every Thursday or Friday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 24 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview, on 01/13/2022 at 8:30 AM, the ADMIN stated that residents' personal laundry was sent home with family or taken to a local laundry mat called by Environmental Staff (EVS). ADMIN stated EVS took resident laundry to be washed several times a week. In an interview, on 01/13/2022 at 8:40 AM, Maintenance Director (MAINT) stated EVS came six days a week to do resident laundry and the process were as follows: a. Nursing staff have all the residents' soiled clothes bagged in a white mesh bag and ready to go to the laundry mat. b. EVS takes the dirty clothes to a local laundromat and uses commercial washers and dryers. c. EVS takes the resident clothes out of the white mesh bag and washes one load at a time using household laundry detergent. d. EVS brings back the clean laundry for residents and drops off the mesh bags in the cubby by the nursing stations for nursing staff to return to the residents. In an interview on 1/13/2022 at 9:09 AM, Director Staff Development stated, We have an outside laundry service that comes in with a cart. She used to take it to [another nearby long term care facility] to be done, but when their laundry is down she has to take it to the laundromat. I have been concerned about the process from an infection control view. There's no way we can monitor temperature regulation, detergent used. No knowledge of what manufacturer specifications are on laundromat washing machines. I never noticed what kind of detergent the laundry service uses. In an interview on 1/13/2022 at 9:11 AM, Infection Preventionist (IP) stated that she is new to her role and has not received training yet in laundry infection prevention requirements. In an interview, on 01/13/2022 at 9:37 AM, EVS stated the following process for laundering resident clothes: I come twice a week and hit Unit B once a week. I pick up the mesh bag from the resident rooms and put it into a plastic bag. I take them to the local laundry mat. Depending on the amount of the laundry I can sometimes put them all together like two different bags for two different residents. I wash the clothes in the mesh bag, I don't take them out of the bag. I use the cheap dollar general pods, no bleach, and I use cold water temps. After the clothes are washed, I take the clothes out of the mesh bag and dry the resident's clothes in their own separate dryer. If there are feces soiled laundry, I bring it back to the facility and tell the nursing staff that they need to go rinse it off in the hopper, and then the clothes goes back into the dirty bag and I wash it again. I bring the clean clothes back to the units and put them back in the resident rooms. I don't let the staff know when I arrive with the clothes. In an interview on 01/13/2022 at 10:23 AM, DON and ADMIN stated they were not aware of any issues related to laundry process for resident clothing. During an interview on 01/13/2022 at 10:55 AM, Infection Preventionist (IP) stated the MAINT was responsible for EVS competencies and training. During a concurrent observation and interview, on 01/13/2022 at 11:05 AM, EVS stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 25 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some receive training or education on her job responsibilities as laundry staff/personnel. EVS confirmed she did not identify resident's laundry bags by name on log sheet, but by room number only. During an observation, EVS confirmed that Resident 22 had dirty laundry (in a white mesh bag) inside resident's closet on Unit C and stated she will be washing resident laundry for unit C tomorrow (1/14/2022). A review of Guidelines for Environmental Infection Control in Health-Care Facilities recommendations of Centers of Disease Control (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC), revised July 2019, indicated the standard for laundry processing: Hot water provides an effective means of destroying microorganisms.1277 A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot-water washing.2 Water of this temperature can be provided by steam jet or separate booster heater.120 The use of chlorine bleach assures an extra margin of safety.1278, 1279 A total available chlorine residual of 50-150 ppm is usually achieved during the bleach cycle.1277 Chlorine bleach becomes activated at water temperatures of 135°F-145°F (57.2°C-62.7°C). The last of the series of rinse cycles is the addition of a mild acid (i.e., sour) to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift in pH from approximately 12 to 5 is an effective means to inactivate some microorganisms.1247 Effective removal of residual alkali from fabrics is an important measure in reducing the risk for skin reactions among patients. 2. Dietary services did not meet the nutritional and palatability needs of resident and did not follow national standards and guidelines for kitchen cleanliness, food temperatures, and storage. During a concurrent interview and document review on 1/13/2022 at 2:05 PM with ADMIN, the facility's QAPI plan and meeting minutes were reviewed. ADMIN stated the facility had not identified or implemented improvement plans to address dietary services, kitchen, and resident laundry concerns identified during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 26 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and implement plans of action to correct deficiencies when: 1. Laundry services for residents did not meet standards for sanitation and infection control. This failure resulted in resident clothing not being cleaned and sanitary and had potential for the spread of diseases and infection throughout the facility. Refer to F880. 2. Dietary services did not meet the nutritional and palatability needs of residents. These failures created the potential for residents to receive food that did not comply with the physician ordered diet, did not meet resident nutritional needs, and had the potential to compromise residents' medical status, nutritional status, and quality of life. Refer to F803, F804, and F805. 3. Dietary services did not follow national standards and guidelines for kitchen cleanliness, food temperatures, and storage. These failures had the potential for the spread of infection, and foodborne illness to occur in residents. Refer to F812. Findings: A review of the facility's policy and procedure titled, Quality Assessment and Assurance Committee, revised 8/2006, indicated the Administrator (ADMIN) was responsible for delegating necessary actions and processes to the QAPI committee. Primary responsibilities of the committee included overseeing facility systems, processes, and appropriate practices in resident care; identifying and resolving negative outcomes relevant to resident care; monitoring, evaluating, developing, and implementing action plans to achieve quality goals. 1. In an interview on 1/13/2022 at 9:09 AM, Director Staff Development stated, We have an outside laundry service that comes in with a cart. She used to take it to [another nearby long term care facility] to be done, but when their laundry is down she has to take it to the laundromat. I have been concerned about the process from an infection control view. There's no way we can monitor temperature regulation, detergent used. No knowledge of what manufacturer specifications are on laundromat washing machines. I never noticed what kind of detergent the laundry service uses. In an interview on 1/13/2022 at 9:11 AM, Infection Preventionist (IP) stated that she was new to her role and had not received training yet in laundry infection prevention requirements. In an interview, on 01/13/2022 at 9:37 AM, EVS stated the following process for laundering resident clothes: I come twice a week and hit Unit B once a week. I pick up the mesh bag from the resident rooms and put it into a plastic bag. I take them to the local laundry mat. Depending on the amount of the laundry I can sometimes put them all together like two different bags for two different residents. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 27 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wash the clothes in the mesh bag, I don't take them out of the bag. I use the cheap dollar general pods, no bleach, and I use cold water temps. After the clothes are washed, I take the clothes out of the mesh bag and dry the resident's clothes in their own separate dryer. If there are feces soiled laundry, I bring it back to the facility and tell the nursing staff that they need to go rinse it off in the hopper, and then the clothes goes back into the dirty bag and I wash it again. I bring the clean clothes back to the units and put them back in the resident rooms. I don't let the staff know when I arrive with the clothes. In an interview on 01/13/2022 at 10:23 AM, DON and ADMIN stated they were not aware of any issues related to laundry process for resident clothing. In an interview on 01/13/2022 at 10:55 AM, Infection Preventionist (IP) stated the MAINT was responsible for EVS competencies and training. During a concurrent observation and interview, on 01/13/2022 at 11:05 AM, EVS stated she did not receive training or education on her job responsibilities as laundry staff/personnel. EVS confirmed she did not identify resident's laundry bags by name on log sheet, but by room number only. During an observation, EVS confirmed that Resident 22 had dirty laundry (in a white mesh bag) inside resident's closet on Unit C and stated she would be washing resident laundry for unit C tomorrow (1/14/2022). 2. a. menus not being followed, and potential for residents to receive the wrong caloric intake and/or physician ordered diet, which could further compromise their medical status and quality of life. b. meals served at a temperature that did not meet the individual preferences of two Residents (Residents 36 and 246), and potential for decreased food intake, and weight loss, which could further compromise their medical status. c. pureed foods for seven residents (Residents 7, 8, 32, 40, 252, 244, and 396) not prepared in accordance with standards of practice and departmental policies. 3. a. The facility kitchen staff were not following the departmental dress code b. Internal bin of the ice machine had an area with pink,clear slimy appearing material c. The kitchen areas and equipment were not clean. d.Refrigerated food were not labeled, dated, monitored and raw foods were not separated from ready-to-eat foods. e. Potentially hazardous foods (PHF) were not at safe temperatures below 41°F. During a concurrent interview and document review on 1/13/2022 at 2:05 PM with ADMIN, the facility's QAPI plan and meeting minutes were reviewed. ADMIN stated the facility had not identified or implemented improvement plans to address dietary services, kitchen, and resident laundry concerns identified during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 28 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure Center of Disease Control (CDC) infection control standards for residents' soiled laundry were implemented. This failure resulted in residents' clothing not being cleaned and sanitary and had the potential to spread disease and infection throughout the facility. Residents Affected - Some Findings: A review of a facility policy titled, Infection Control Manual - Laundry Department dated 5/7/2019, indicated, It is the policy of this facility to practice safe and sanitary laundry procedures, and the purpose of the policy is to decrease the risk of disease transmission . and ensure an effective infection control program. Administrative staff act jointly with the infection control committee to create policies and procedures to laundering resident's personal clothing. Monitor linen handling in resident care and laundry areas to ensure proper procedures are followed. Act jointly with infection control committee in making periodic facility inspection to ensure infection control standards consistently maintained. Soiled linen will be removed from the resident's room and placed in a sealed soiled linen container and kept away from closets. Laundry supervisor will perform set standards for department in accordance with all local, state, federal law and standards (CDC), regulations and guidelines. Implement effective systems for laundry sanitation including regular cleaning and maintenance for all linen areas. Train staff in all policies and procedures pertaining to use of equipment and infection control. In an interview on 01/11/2022 at 11:31 AM, a family member (RP) 1 stated, I do my husband's laundry because the laundry here sucks. They washed his clothes in the mesh bag without taking it out and I found food stuck on the clothes after they had supposedly been washed. In a concurrent observation and interview, on 01/11/2022 at 2:10 PM, a white mesh bag with dirty laundry belonging to Resident 22 was observed in his closet. Certified Nursing Assistant (CNA) J confirmed the white mesh bag had dirty laundry and stated that laundry services were every Thursday or Friday. In an interview, on 01/13/2022 at 8:30 AM, the Administrator (ADMIN) stated that residents' personal laundry was sent home with family or taken to a local laundry mat called by Environmental Staff (EVS). ADMIN stated EVS took resident laundry to be washed several times a week. In an interview, on 01/13/2022 at 8:40 AM, Maintenance Director (MAINT) stated EVS came six days a week to do resident laundry and the process were as follows: a. Nursing staff have all the residents' soiled clothes bagged in a white mesh bag and ready to go to the laundry mat. b. EVS takes the dirty clothes to a local laundromat and uses commercial washers and dryers. c. EVS takes the resident clothes out of the white mesh bag and washes one load at a time using household laundry detergent. d. EVS brings back the clean laundry for residents and drops off the mesh bags in the cubby by the nursing stations for nursing staff to return to the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 29 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 In an interview on 01/13/2022 at 9 AM, Licensed Nursing staff (LN) N stated, Laundry services are an ongoing problem and have not been consistent with cleaning and washing residents' clothing. LN N statedand the clothes turned up wrinkled and still dirty at times with food. LN N also stated better communication was needed between laundry staff and floor staff to know when resident clothes were picked up for washing and when they were returned to the unit. Residents Affected - Some During an observation, on 01/13/2022 at 9:05 AM, the white mesh bag with dirty laundry was still in Resident 22's closet. In an interview on 1/13/2022 at 9:09 AM, Director of Staff Development stated, We have an outside laundry service that comes in with a cart. She used to take it to [another nearby long term care facility] to be done, but when their laundry is down she has to take it to the laundromat. I have been concerned about the process from an infection control view. There's no way we can monitor temperature regulation, detergent used. No knowledge of what manufacturer specifications are on laundromat washing machines. I never noticed what kind of detergent the laundry service uses. In an interview on 1/13/2022 at 9:11 AM, Infection Preventionist (IP) stated that she was new to her role and had not received training yet in laundry infection prevention requirements. In an interview, on 01/13/2022 at 9:37 AM, EVS stated the following process for laundering resident clothes: I come twice a week and hit Unit B once a week. I pick up the mesh bag from the resident rooms and put it into a plastic bag. I take them to the local laundry mat. Depending on the amount of the laundry I can sometimes put them all together like two different bags for two different residents. I wash the clothes in the mesh bag, I don't take them out of the bag. I use the cheap dollar general pods, no bleach, and I use cold water temps. After the clothes are washed, I take the clothes out of the mesh bag and dry the resident's clothes in their own separate dryer. If there are feces soiled laundry, I bring it back to the facility and tell the nursing staff that they need to go rinse it off in the hopper, and then the clothes goes back into the dirty bag and I wash it again. I bring the clean clothes back to the units and put them back in the resident rooms. I don't let the staff know when I arrive with the clothes. In an interview on 01/13/2022 at 10:23 AM, DON and ADMIN stated they were not aware of any issues related to laundry process for resident clothing. During an interview on 01/13/2022 at 10:55 AM, IP stated the MAINT was responsible for EVS competencies and training. Review of a record titled, Laundry List, indicated the following information should be filled out on the form: a. Resident name b. Laundry taken OUT for cleaning and brought back IN after cleaning c. Pick Up Days d. Number of Soiled Linen Bags and Clean Linen Bags (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 30 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 The record indicated laundry for residents were identified by room numbers; no resident names were recorded; and no record of the total number soiled/clean linen bags were noted for the following dates: 12/15/2021-12/17/202 and 12/21/2021-12/24/2021. In a concurrent observation and interview on 01/13/2022 at 11:05 AM, EVS stated she did not receive training or education on her job responsibilities as laundry staff/personnel. EVS confirmed she did not identify resident's laundry bags by name on log sheet, but by room number only. During an observation, EVS confirmed that Resident 22 had dirty laundry (in a white mesh bag) inside resident's closet on Unit C and stated she would be washing resident laundry for unit C tomorrow (1/14/2022). A review of Guidelines for Environmental Infection Control in Health-Care Facilities recommendations of Centers of Disease Control (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC), revised July 2019, indicated the standard for laundry processing indicated tghe following: Hot water provides an effective means of destroying microorganisms. A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot-water washing.2 Water of this temperature can be provided by steam jet or separate booster heater.120 The use of chlorine bleach assures an extra margin of safety.1278, 1279 A total available chlorine residual of 50-150 ppm is usually achieved during the bleach cycle.1277 Chlorine bleach becomes activated at water temperatures of 135°F-145°F (57.2°C-62.7°C). The last of the series of rinse cycles is the addition of a mild acid (i.e., sour) to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift in pH from approximately 12 to 5 is an effective means to inactivate some microorganisms.1247 Effective removal of residual alkali from fabrics is an important measure in reducing the risk for skin reactions among patients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 31 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 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. 4) During an observation on nursing unit C, on 01/10/2022 at 11:10 AM, it was noted the shower room sink had a small clump of gray hair that had not been cleaned out. Residents Affected - Some In a concurrent observation and interview with Certified Nursing Assistant (CNA) J, on 01/10/2022 at 11:16 AM, CNA J stated staff rinsed out used wash cloths in sink but they didn't wash resident's hair in the sink. CNA J confirmed there was a clump of gray hair in sink drain in the shower room on nursing unit C. 5) Review of a facility policy titled, Medication Administration, revised 02/2013, indicated that, The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly. On 01/12/2022 at 08:16 AM, it was observed that the Medication Storage room on nursing unit C had a moderate amount of dirt and dust on the floor, and empty shipping boxes with corrugated cardboard stored under the medication supplies. In an interview with Housekeeping (HK) G, on 01/12/2022 at 11:09 AM, HK G stated housekeeping was not given the assignment of cleaning the medication storage rooms, and that it was the responsibility of the maintenance department. During a concurrent observation and interview on 01/12/2022 at 11:32 AM, LN H confirmed the Medication Storage room on nursing unit C had a moderate amount of dirt and dust on the floor, and empty shipping boxes with corrugated cardboard were stored under resident medication supplies. LN H also stated that only licensed nursing staff have access to the locked medication room, and housekeeping would asked the licensed nurse in charge to open the medication room to clean it. In an interview on 01/12/2022 at 11:45 AM, Director of Staff Development (DSD) and Infection Preventionist (IP) both stated that housekeeping was responsible for cleaning the medication storage rooms. During an interview on 01/12/2022 11:56 AM, LN I stated that housekeeping would ask licensed nursing staff to open the medication room for cleaning, but could not recall the last time housekeeping asked to clean the medication storage rooms. In a concurrent observation and interview on 01/12/2022 at 2:03 PM, Director of Nursing (DON) stated he checked the medication storage rooms once a month and would call on housekeeping to clean the medication room. DON confirmed there was no record or log of Medication Storage room cleaning. DON acknowledged the Medication Storage room on nursing unit C had a moderate amount of dirt and dust on the floor and needed to be cleaned. He also confirmed there were empty shipping boxes with corrugated cardboard stored under the medication supplies and stated they should not be there and was observed removing the boxes. Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment when: 1) The Contracted Kitchen (in the nearby assisted living facility where food for this facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 32 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0921 prepared) had broken floor tiles, damaged/uncleanable wall and door surfaces, a plumbing leak, and inadequate hot water at the handwashing sink; Level of Harm - Minimal harm or potential for actual harm 2) The Facility Kitchen had chipped paint/soiled doors, and a broken light cover; Residents Affected - Some 3) The heat for the shower room on nursing unit B was broken; 4) The Medication Storage room on nursing unit C had an accumulation of dirt and dust on the floor and corrugated shipping boxes stored under medication supplies; and 5) Hair was left in shower room sink on nursing unit C. These failures resulted in an unsanitary, uncomfortable and unhomelike environment with the potential for infection and causing residents to avoid showering, and resident medication supplies stored in an unsanitary environment. Findings: 1) A review of the 2017 Food and Drug Administration (FDA) Food Code §6-501.11 showed, Physical Facilities shall be maintained in good repair. §4-202.16 showed, Non-food-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. §6-501.12 Physical Facilities shall be cleaned as often as necessary to keep them clean. §4-601.11 showed It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The 2017 FDA Food Code Annex §4-602.13 explained 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. Observations with concurrent interviews in the Contracted Food Service Kitchen between 1/10/22 at 9:45 AM and 1/11/22 at 4 PM showed: 1A) Broken Floor Tile - During an observation on 1/10/22 at 10:08 AM, there were broken floor tiles at the base of a pillar across from the cook's food preparation sink. On 1/11/22 at 10 AM broken/uncleanable floor tiles were observed in the walk-in refrigerator/freezer at the freezer door. 1B) Damaged/Uncleanable Wall and Door Surfaces - During an observation on 1/10/22 at 10:08 AM, exit doors and door trim in the contract kitchen had damaged wood surfaces and chipped paint, resulting in uncleanable surfaces. Additionally, the trim on a pillar across from the food preparation sink was pulled away from the wall, providing an uncleanable surface and potential harborage for pests. 1C) Plumbing Leak - During an observation and concurrent interview on 1/10/22 at 10:08 AM capped off plumbing protruded from a wall near the free-standing mixer and dripped water onto the lower shelf of a stainless-steel cart. 1D) Warm water was not provided in a timely manner - Review of California Health and Safety Code (HSC) Article 4, 113953 (c) showed, Handwashing facilities shall be equipped to provide warm water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 33 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some under pressure for a minimum of 15 seconds through a mixing valve or combination faucet. If the temperature of water provided to a handwashing sink is not readily adjustable at the faucet, the temperature of the water shall be at least 100°F, but not greater than 108°F. The handwashing sink had inadequate hot water. During an observation and concurrent interview on 1/10/22 at 9:50 AM, water at the handwashing sink was not warm despite continuous running as 3 surveyors consecutively washed their hands - approximately 3 minutes. The water temperature was 69.1°F (degrees Fahrenheit - a unit of measure) after the third surveyor washed her hands. The FNSD stated, It takes a while for hot water to get there. During an observation on 1/11/22 at 10 AM it also took approximately 3 minutes for warm water to arrive at the handwashing sink. Review of a policy titled, Hand Washing Procedure, dated 2018 showed, Procedure: Use warm running water. 2) During observations with concurrent interviews in the Facility Kitchen between 1/10/22 at 9:15 AM and 1/13/22 at 4 PM showed: 2A) Chipped Paint/Soiled Doors During an observation on 1/10/22 at 9:15 AM, the door from the facility lobby into the facility kitchen had chipped paint and was heavily soiled on both the interior and exterior surfaces. During an observation and concurrent interview in the facility kitchen on 1/10/22 at 3:23 PM, the soiled/damaged door between the kitchen and the lobby was reviewed with the Maintenance Director (MAINT). He agreed the door was not clean and stated this is not clean. When asked how often the chipped paint/ damaged surfaces get taken care of, he stated the whole facility was painted inside and out a few months ago but the kitchen was not painted. It's hard to find a time to paint the kitchen. It would have to be done at night. 2B) Broken Ceiling Light Cover During an observation and concurrent interview in the kitchen with the MAINT on 1/10/22 at 2:57 PM, he was asked about the cracked cover on the ceiling light fixture near tray line. He stated I order things and sometimes they take a long time to come in. 3) A review of the facility's policy titled, Building Systems Heating, Ventilation, and Air Conditioning, indicated that, It is the policy of this facility to maintain buliding systems in good working order, inspecting them at interveals which comply with state, federal and company standards to repair as necessary. In an observation and concurrent interview on 1/11/2022 at 9:15 AM, Maintenance Supervisor (MAINT) was asked to check the temperature of the shower room. MAINT initially read the temperature on his thermometer at 75°F. MAINT was instructed to reset the thermometer and took another reading. MAINT acknowledged that his reading had been incorrect. Two subsequent readings read 66°F both times. MAINT stated, The goal should be 71°F. Right now it's off. The heat was off for that room, the compressor has been broken for about two weeks. MAINT called [a local repair company] to come out to fix it. MAINT stated on two occasions that he would provide evidence of intent to repair but did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 34 of 35 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 555802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Crest Post-Acute 50 Concordia 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 0921 not provide the requested record. Level of Harm - Minimal harm or potential for actual harm In an interview on 1/10/2022 at 11:10 AM, Resident 247 stated, Shower room cold? [Expletive] yeah, it's cold every time you go in there! Residents Affected - Some In an observation on 1/11/2022 at 9 AM, the facility's shower room on B station temperature was read as 67.7°F following two readings with two different thermometers. In an observation and concurrent interview on 1/11/22 09:10 AM Resident 27 was observed being taken out of the shower room and stated, It's cold in there! In an interview on 1/10/2022 10:27 AM, Resident 28 stated that her toilet and sink had been clogged for approximately one week, causing staff to take her to the shower room to use the toilet, where it was uncomfortably cold. Resident 28 stated, The shower room was freezing on off-hours. I'm uncomfortable in there. In an interview on 1/11/22 at 2:18 PM Licensed Nurse (LN) A stated, We've known about [the lack of heat] for a while. The girls were going in before residents shower to run hot water and heat the room up. LN A stated that she was unsure of whether the room was warmed prior to Resident 28's off-hour use while her toilet was clogged. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 35 of 35

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Citations

16 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.

0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0726GeneralS&S Dpotential for harm
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
0801GeneralS&S Fpotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0802GeneralS&S Epotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0804GeneralS&S Fpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0835GeneralS&S Epotential for harm
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
0867GeneralS&S Epotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0921GeneralS&S Epotential for harm
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.
0223GeneralS&S Dpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0712GeneralS&S Dpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.

FAQ · About this visit

Common questions about this visit

What happened during the January 18, 2022 survey of COUNTRY CREST POST-ACUTE?

This was a inspection survey of COUNTRY CREST POST-ACUTE on January 18, 2022. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at COUNTRY CREST POST-ACUTE on January 18, 2022?

Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."

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.

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·January 18, 2022