Inspection·June 10, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received wound preventative measures as ordered to prevent skin breakdown, promote circulation, and provide pressure relief. Residents Affected - Few This failure resulted in Resident 1 sustaining a stage 2 pressure ulcer (partial-thickness skin loss, where the epidermis (outer layer) and part of the dermis (second layer) are damaged caused by prolonged pressure) to their coccyx (tailbone), which had the potential to lead to complications including pain, discomfort, and infection. Findings: During a record review of the facility policy titled Skin Integrity Management Protocol dated 1/2019, it was indicated that staff were to relieve the underlying cause, addressing pressure, shear, other physical friction, and maceration/moisture factors. The facility policy indicated to keep local areas clean, dry, and free of body wastes such as urine, feces, perspiration, and wound drainage. The policy indicated to inspect skin frequently for indications of hyperemia (redness, swelling, and warmth), non-blanchable erythema (redness of the skin or mucous membranes), or disruption of skin integrity .sacrum/coccyx, and buttocks and to apply skin A&D ointment (zinc oxide) as indicated for skin maintenance. During a record review of the facility job description for Certified Nursing Assistants (CNAs) undated, it was indicated that facility CNAs were to observe and report the presence of pressure areas and skin breakdowns to prevent bedsores. A record review of Resident 1's admission record indicated they were admitted to the facility on [DATE] with diagnoses that included an intertrochanteric fracture of the right femur (a break in the upper part of the thigh bone) after a fall at home with Open Reduction Internal Fixation (ORIF - a surgical procedure used to repair broken bones, particularly in cases where the bone is displaced or comminuted), protein-calorie malnutrition (nutritional status with reduced availability of nutrients leads to changes in body composition and function), panic disorder (frequent and unexpected panic attacks), and hypokalemia (a low potassium level in blood). Resident 1 was their own responsible party (made their own financial and medical decisions). During a record review of Resident 1's Minimum Data Set (MDS - a standard assessment tool used in nursing homes and other long-term care facilities to collect data on residents' health and functional status) Section H Bowel and Bladder dated 9/26/24, Resident 1 was assessed as occasionally incontinent for urine and always incontinent for bowel. (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 3 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 06/10/2025 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)