Health inspection·April 17, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report injury of unknown origin for one resident (Resident 1) out of three sampled residents reviewed for abuse within 2 hours, to the California Department of Public Health (CDPH). This failure had the potential to delay investigation and interventions to prevent abuse to other residents in the facility. Findings: The facility ' s policy revised1/10/24, titled Abuse Reporting and Investigation, indicated to promptly report all allegations of abuse as required by law and regulations to appropriate agencies within the required time frames. All allegations of abuse, neglect, exploitation, or injury of unknown cause/origin shall be reported to the Abuse Prevention Coordinator (APC) immediately. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property shall be reported by APC/Designee to local CDPH, Long Term Care Ombudsman and Local Law Enforcement either by telephone, email, or in writing (SOC 341, form to report alleged abuse or injury of unknown source) immediately. A review of Resident 1 ' s record indicated she had been admitted to the facility on [DATE] for diagnoses that included Urinary Tract Infection (UTI, bladder infection), dementia (a progressive brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks), cognitive communication deficit (problems with the ability to think, learn, remember, use judgement, and make decisions), Diabetes (a disease when the body has too much sugar in the blood) and need for personal care. Resident 1 was unable to make her own decisions and did have a responsible party. During an observation on 4/17/24 at 12:17 pm, Resident 1 had a circular, dark purple discoloration, approximate size was 3 centimeters (cm, a unit of measure) by 2 cm on the lateral upper left arm. Resident 1 denied pain or discomfort of left arm. During an interview on 4/17/24 at 12:20 pm, with Licensed Nurse (LN) A, LN A stated, I would have reported this injury to Resident 1 to the abuse coordinator to follow up with an investigation and put Resident 1 on alert charting to monitor. It looks like a bruise with a blood blister in the middle. During a concurrent record review and interview with the Director of Nursing (DON) on 4/17/24 at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 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 04/17/2024 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)