Health inspection·November 5, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few usually received 15-20 brief changes every 24 hours. CNA E confirmed Resident 1 was a Heavy wetter. CNA E stated that facility staff were generally aware that Resident 1 was Very incontinent. CNA E stated, It would be strange for [Resident 1] to receive only 2-4 brief changes in a 24-hour period. During an interview with CNA F on [DATE] at 10:03 am, CNA F confirmed she worked the Night shift for [DATE], [DATE], and [DATE]. CNA F confirmed Resident 1 was a Heavy wetter and 15-20 brief changes in a 24-hour period was Normal for her. During an interview with CNA G on [DATE] at 11:06 am, CNA G confirmed 2-4 brief changes in a 24-hour period for Resident 1 was Not enough. Because [Resident 1] was always incontinent.During an interview with Licensed Nurse (LN) H on [DATE] at 11:14 am, LN H stated [Resident 1] needed multiple brief changes a day, and 2-4 brief changes a day was not like her elimination baseline. During an interview with Director of Nursing (DON) on [DATE] at 12:19 pm, DON stated he was not aware there was a decrease in the number of brief changes for Resident 1. DON confirmed this was considered a change in condition and both MD and DON should have been notified of this, especially since Resident 1 had a history of Urinary tract infection (UTI - an infection in any part of the urinary system). 2. During a review of Resident 1's clinical record titled Blood Sugar Summary, dated [DATE] - [DATE], indicated Resident 1's average blood sugar levels were between 250 - 300 milligrams per deciliter (mg/dL, a unit of measurement) and Resident 1's Blood Sugar level elevated to above 320 to 430 mg/dL from [DATE] to [DATE]. (blood sugar level above 400 was very dangerous and could lead to a life-threatening condition) [DATE] 7:49 am - Blood Sugar level of 268 mg/dL[DATE] 7:40 am - Blood Sugar level of 265 mg/dL[DATE] 7:53 am - Blood Sugar level of 238 mg/dL[DATE] 8:23 am - Blood Sugar level of 274 mg/dL[DATE] 7:47 am - Blood Sugar level of 345 mg/dL[DATE] 6:44 am - Blood Sugar level of 320 mg/dL[DATE] 7:39 am - Blood Sugar level of 356 mg/dL[DATE] 7:35 am - Blood Sugar level of 434 mg/dL[DATE] 7:54 am - Blood Sugar level of 408 mg/dLDuring a review of Resident 1's clinical record titled SBAR, dated [DATE] at 12:44 pm, indicated LN H notified MD, Nurse called MD for Resident 1 having high fasting blood glucose (FBG - the level of glucose (sugar) in the blood after fasting for at least 8 hours) before breakfast 434 mg/dL and before lunch 353 mg/dL. New order received for Complete Blood Count (CBC- a common blood test that measures various components of the blood to assess overall health and detect potential medical conditions)/ Comprehensive Metabolic Panel (CMP- a routine blood test that provides an overview of the body's chemical balance and metabolism)/ Hemoglobin A1C (Hb A1C - a blood test that measures the average blood sugar levels over the past two to three months) one time only for one day. MD recommendation was to Monitor and new order for labs.During a review of Resident 1's physician orders, dated [DATE] at 12:30 pm, indicated CBC/CMP/HbA1C one time only for one day During a review of Resident 1's clinical record titled Laboratory Result, dated [DATE] at 12:54 pm, indicated LN A documented Notified by lab that Resident 1 refused ordered labs today. MD notified and gave order to try again tomorrow. Lab slip placed in lab book per policy. Lab will attempt again tomorrow morning.During a review of the facility's lab requisition binder, a local phlebotomist (a healthcare professional who specializes in drawing blood from residents) documented no labs on the lab draw log on [DATE], the date Resident 1's lab draw was ordered to be done. During a review of Resident 1's progress notes, dated [DATE] at 7:09 am, by LN H, indicated LN H received a report from night shift staff that [Resident 1] was calling out all night. [Resident 1] had FBG 258 mg/dL and pulse 40 (normal range 60-100 beats per minute) thready (a weak pulse), and SPO2 (Oxygen levels) was 87% on room air. [Resident] 1 was transferred to the emergency room on [DATE]. During an interview with DON on [DATE] at 1:56 pm, DON stated if a lab order is refused by a resident, the lab slip would be placed back into the lab requisition binder for the next day and notify the MD. DON stated he could not remember if LN H told him about Resident 1's change in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 2 of 4 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 11/05/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition on [DATE]. During a concurrent interview with LN A on [DATE] at 2:10 pm, the facility's lab requisition binder was reviewed. LN A confirmed that if the phlebotomist wrote no labs in the lab requisition binder, then there were no lab slips for the phlebotomist to reference for that day. LN A confirmed phlebotomist wrote no labs in lab requisition binder on [DATE]. LN A stated that she could not remember if she put a lab slip in the binder for [DATE] and confirmed that there was not one in the binder. LN A stated after Resident 1 refused the lab draw for [DATE], she forgot to enter the verbal lab order received from MD for [DATE]. LN A stated that a new lab order was needed in order for Resident 1 to successfully receive a lab draw on [DATE].During an interview with the supervisor of a local lab company (S LAB) on [DATE] at 3:30 pm, S LAB stated that no labs written on the lab requisition log indicated no lab slips were in the binder for the phlebotomist to reference. S LAB stated if a resident refused a lab draw, the phlebotomist would document on the lab draw log in the lab requisition binder with the resident's name, type of lab ordered, and write refused. S LAB confirmed no labs was documented in the lab draw log for [DATE], and Resident 1's name was not on the log. During an interview with CNA D on [DATE] at 9:40 am, CNA D stated that Resident 1 was not someone who routinely refused medications or care.During an interview with CNA E on [DATE] at 9:50 am, CNA E stated Resident 1 only refused care to new staff but accepted care if new staff took their time and spoke with her.During an interview with CNA F on [DATE] at 10:03 am, CNA F confirmed she worked the night shift for [DATE], [DATE], and [DATE]. CNA F stated [Resident 1] screamed out Help me! Lord, help me! Help me! during her shift all three nights. CNA F stated Resident 1's roommate pressed the call light one night to get staff to help calm Resident 1. CNA F stated she reported Resident 1's calling out to LN C on [DATE], [DATE], and [DATE] during their shift. CNA F stated that she did not see LN C leaving nurse's station to assess Resident 1 during the shifts when she reported Resident 1 screaming. During an interview with MD on [DATE] at 10:42 am, MD stated he was notified by staff on [DATE] that Resident 1 refused the lab draw and he gave a verbal order for the lab to attempt the lab draw on [DATE]. MD stated he was not notified that the labs were never drawn. MD stated he would have expected to be notified that labs were not drawn as ordered. MD stated he expected the facility to follow up to ensure the labs were drawn if the first attempt was not successful. MD stated he was not notified that Resident 1 cried out for help on [DATE], [DATE] or [DATE]. MD stated this would be considered a change in condition for Resident 1 and that facility should have notified him because he would have sent Resident 1 Out immediately for evaluation.During an interview with CNA G on [DATE] at 11:06 am, CNA G stated [Resident 1] would not scream out or cry out for help at her baseline. CNA G stated Resident 1 was Generally a quiet person. During an interview with LN H on [DATE] at 11:14 am, LN H stated she was told by night shift nurse LN A that Resident 1 refused lab draw on [DATE]. LN H stated it was not the nurse's job to ask a resident if they wanted lab work. LN H stated it was the job of the phlebotomist to ask the resident. LN H stated after she notified MD of Resident 1's high blood glucose levels on [DATE], and he gave her a verbal order for labs to be drawn on [DATE]. LN H stated she entered the order electronically and filled out a lab slip. LN H stated she placed the lab slip into the facility lab binder. LN H stated she did not work on [DATE] and did not follow up to ensure Resident 1's lab order was fulfilled as ordered. During an interview with DON on [DATE] at 12:19 pm, DON confirmed that an increase in blood glucose levels would be considered a change in condition that the MD and the DON should be notified of immediately. DON confirmed LN A should have entered a new lab order electronically for [DATE]. DON confirmed it was his job to follow up on lab work for residents and ensure it was completed as ordered. DON confirmed he did not follow up on Resident 1's lab work.During an interview with LN C on [DATE] at 2:20 pm, LN C confirmed he worked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555802 If continuation sheet Page 3 of 4 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 11/05/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the night shift for [DATE], [DATE] and [DATE]. LN C stated he couldn't recall whether Resident 1 called out for help. LN C confirmed he did not assess Resident 1 for a change in condition. LN C stated Resident 1 appeared more Confused on [DATE], and he called MD, but MD did not answer. LN C confirmed he did not call MD again, nor notify DON or Administrator (Admin) of change in condition. During a review of Resident 1's clinical record titled Hospitalist: History and Physical, dated [DATE], at 9:56 AM, by Hospital MD, Resident 1 was admitted to the hospital with the following diagnoses: Septic shock: A life-threatening condition that occurs when an infection spreads throughout the body and causes a severe drop in blood pressure. Acute respiratory failure with hypoxia: A life-threatening condition where the lungs cannot adequately provide oxygen to the body. Profound hyperkalemia: A life-threatening condition where blood potassium levels are dangerously high, potentially causing fatal abnormal heart rhythm. Acute kidney injury with anuric renal failure: A condition where the kidneys suddenly lose their ability to function properly, no urine output whatsoever. Resident 1's BUN profoundly elevated at 287, emergent hemodialysis (a life-saving treatment for acute kidney failure) was performed. Hypovolemic Hypernatremia: a condition where there is a loss of both water and sodium, but more water is lost than sodium, resulting in a higher concentration of sodium in the blood and a decrease in overall body fluid volume Metabolic acidosis/Lactic acidosis: a condition where there is too much acid in the blood, occurring when the body either produces too much acid or the kidneys cannot remove enough of it. Lactic acidosis is a specific type of metabolic acidosis caused by an excess buildup of lactic acid in the blood, often due to insufficient oxygen delivery to the body's tissues.Hospital MD also indicated in the assessment and plan, Septic shock, admit to intensive care unit (ICU - a special hospital area for patients with life-threatening illnesses who require constant monitoring and advanced life support), will be a miracle if this patient survives.During a review of Resident 1's physician order, Resident 1 was placed on hospice care, returned to the facility on [DATE] and passed away on [DATE]. Event ID: Facility ID: 555802 If continuation sheet Page 4 of 4