Oroville Hospital Post-Acute Center

Inspectors wroteBased on interview and record review the facility failed to ensure staff assigned to perform food and nutrition services possessed the competencies and skill sets necessary to carry out those functions. When the facility utilized Certified Nursing Assistants (CNA) to prepare and alter food without documented training or competency validation. These failures had the potential to place residents, a highly susceptible population, at risk of receiving improperly prepared or altered meals that did not meet prescribed therapeutic diets, texture modification, nutritional requirements.

Inspectors wroteBased on observation and interview the facility failed to maintain food safety requirements in the kitchen for all residents receiving their nutritional intake from the kitchen when a gallon of milk and a jar of dill pickle relish were not labeled with the open date following the opening and use of the products. This failure had the potential to result in improper prolonged, out of date use leading to disease transmission, increasing environmental health complications, and overall wellbeing issues to those residents' receiving their nutritional intake from the facility kitchen.

Inspectors wroteBased on interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS). This failure has the potential for nursing homes to have inadequate staffing to care for residents and can lead to adverse clinical outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain essential equipment in operable condition affecting all residents that partake in nutrition provided by the kitchen facility and residents using bathroom units when:1. The oven in the kitchen had broken doors rendering the unit inoperable to perform the function of cooking.2. The wall by the dishwasher unit had incomplete repairs performed leaving the drywall open to moisture, and potential mold and bacterial growth which could result in infection control issues and food borne illness propagation.3. The bathroom facilities, sink and toilet, in room [ROOM NUMBER] were not working. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and home-like environment for four of 24 sampled residents (Residents 34, 42, 45, and 59) when the facility failed to maintain resident's personal clothing and belongings, resulting in lost clothing items. This failure had the potential to compromise residents' dignity, comfort, and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete:The admission Minimum Data Set (MDS) assessment in a timely manner for one of five sampled residents (Resident 123). The Annual MDS assessments for two of five sampled residents (Residents 14 and 126). These failures had the potential to delay the development of comprehensive care plans necessary to provide appropriate, individualized care and services for Residents 14, 123, and 126 to attain and maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) assessment within 92 calendar days of the previous assessment for two of five sampled residents (Residents 11 and 12). This failure had the potential to delay the development of comprehensive care plans necessary to provide appropriate, individualized care and services for Residents 11 and 12.

Inspectors wroteBased on interview and a review of facility records, the facility failed to maintain adequate nursing staff to meet residents' care needs, when:1. Resident council meetings and resident grievances from January to May 2026 documented delays in staff response to call lights.2. Seven of twenty-four residents reported insufficient direct care staff, resulting in delayed responses to call lights and inadequate assistance with activities of daily living, including toileting, oral care, and pain management. 3. The facility did not take resident acuity (complexity and intensity of care needs) into account when scheduling Certified Nursing Assistant (CNA) staff for the [NAME] and North Nursing Stations. As a result of these staffing deficiencies, resident care needs were not consistently met. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that one out of 24 sampled residents (Resident 46) was free from abuse when Resident 128 punched Resident 46 in the face. The incident resulted in a laceration to Resident 46's upper lip requiring stitches and caused temporary feelings of insecurity regarding personal safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that adequate dialysis (a life-saving medical treatment performed to filter toxins out of the blood) care and services were provided for one of one sampled resident (Resident 42), when: Required dialysis communication forms were missing and incomplete. Licensed Nurses did not perform and document daily assessments of the resident's dialysis fistula (the surgically created access used for dialysis). Resident 42's care plan (a document that described resident goals and the care that would be provided) did not include instructions describing the assessments required for monitoring the fistula. This failure had the potential to result in undetected, life-threatening complication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 12) was free from unnecessary medications when the required psychotropic (a medication that altered the brain) medication informed consent form was not renewed every six months as required. This failure had the potential to compromise Resident 12's ability to maintain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of ten sampled residents (Resident 2) when: 1. Registered Nurse (RN) B willfully took the bed remote from Resident 2 and hid it out of reach.2. RN B willfully shut the door while Resident 2 was yelling for help. 3. RN B willfully left Resident 2 in isolation and neglected to provide services needed. This failure caused involuntary seclusion (isolation) to Resident 2, and the potential for emotional distress, and a fall.

Inspectors wroteBased on interview and record review, the facility failed to follow the care plan for one of three residents (Resident 1) when Resident 1 was left unattended in his room when a hospitality aide (HA - someone hired by the facility to provide non-medical assistance to residents, focused on their comfort, safety, and well-being) took a break and left Resident 1's room. This failure had the potential to result in physical and/or psychosocial harm to other residents when Resident 1 eloped (unsupervised wandering) from his room and entered Resident 2's room.

Inspectors wroteBased on interview, and record review, the facility failed to provide five residents (Residents 2, 14, 73, 130, 292) out of a sample of 32 with the bed hold agreement in writing when residents were transferred out of the facility to a hospital or for therapeutic leave. This failure had the potential for residents to be unaware that, for a period of up to seven days after the transfer, the facility must readmit them when the resident is ready to return, and that the resident has only a 24-hour window in which to inform the facility that they intend to return.

Inspectors wroteBased on interview and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, a standardized resident assessment) for 12 of 29 sampled residents (Residents 41, 44, 7, 87, 73, 27, 55, 96, 100, 291, 293, and 294) when MDS assessments were not completed within 14 days. These failures had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 44 and 41 related to the care areas identified on the Comprehensive MDS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven of twenty-nine sampled residents (Resident 5, 334, 23, 29, 73, 291, and 46) received the necessary treatment and services to maintain ADL's (activities of daily living). when: 1. Resident 5's lunch tray was not set up by staff and therefore she was unable to eat. 2. Resident 334's fingernails were long with black matter underneath them. 3. Resident 23 stated, staff did not assist with oral care or hair brushing unless Resident 23 asked for help. 4. Resident 29's hair was tangled. 5. Resident 73's mucus membranes (the moist, inner lining if the mouth) were dried and contained a thick, white, debris that was attached to the roof of the mouth and the tongue. 6. Resident 291 didn't receive consistent oral care. 7, Resident 46 didn't receive consistent oral care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two out of 29 sampled residents (Residents 44 and 5) when: 1. Coccyx (the skin over the tailbone) treatments were not provided for Resident 44 who had Moisture Associated Skin Damage (MASD, skin breakdown caused by prolonged expsure to moisture). This failure had the potential for Resident 44's health and wellbeing to decline and her skin redness to worsen. 2. The facility failed to ensure consistent assessments of a skin condition for Resident 5. This failure had the potential for a change in condition to go unattended, with possible negative health outcomes for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement downtime policies and procedures (P&P) when there was an internet outage on 12/13/24. This failure caused an inability for facility staff to access the residents electronic medical record (EMR) and could cause a delay in resident care needs.

Inspectors wroteBased on observation, interview, and record review, the facility had a 27.59% medication error rate when eight medication errors out of 29 total opportunities were observed during medication passes for two out of six sampled residents (Residents 73 and 184). These failures had the potential to compromise the resident's health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label drugs in accordance with professional standards when: 1. The label attached to a medication container did not match the Physician's order. 2a. The freezer section, located in the medication refrigerator, of the [NAME] Wing medication storage room, contained ice build up and had icicles hanging from the freezer. 2b. An e-kit, (emergency medication) that was in the medication refrigerator of the [NAME] Wing medication storage room, was placed inside a tray like container that contained ice and clear liquid. 3. The medication cart, located on the [NAME] Wing, contained 2 unlabeled medication cups, each containing resident medication, and a pill cutter (a device that was used to cut pills in half) that was covered in residual pill powder. 4. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure staff were trained, competent and following their training when: *1. The kitchen was not sanitary. *2. Staff did not consistently perform standards of professional practice to prevent cross contamination. *3. Staff did not consistently complete or document ambient food cooling temperature checks. *4. Pureed fish did not have a palatable consistency.

Inspectors wroteBased on observation, interview and record review the facility did not follow a preplanned standardized menu cycle or cooks spreadsheets for vegetarian meals, and had the potential to not meet the nutritional needs of vegetarian residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at an appetizing temperature when four out of twenty nine residents interviewed (Resident 29, 44, 54, 284) stated the food was cold. This failure had the potential to result in decreased resident meal intakes, weight loss, and decline in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure six resident's (Resident #70, #288, #334, #336, #338) individual texture needs were met when the food consistencies provided did not meet facility diet manual standards or resident preferences. This failure had the potential to result in resident's inability to consume their food resulting in decreased intakes and decline, or to potentially result in choking and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when: 1. The kitchen was not sanitary. 2. Kitchen staff did not follow professional standards of practice to avoid cross contamination in food production processes. 3. Ambient food cool down process was not performed consistently when indicated. 4. There was not an effective process in place for management of dented cans. 5. Three out of three nursing unit nourishment rooms were not sanitary. 6. Chemicals that were not food-safe were used to clean food contact surfaces in nursing unit nourishment rooms. These failures had the potential to spread infection and cause food borne illness for residents consuming food in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitary food storage for resident's personal food in three out of three nursing unit nourishment rooms. Resident food stored in the freezer were not labeled with patient identifiers (name, room number and date) to ensure the correct patient received their personal food items. These failures had the potential to cause foodborne illness and decline in residents, and to decrease resident's quality of life if personal foods were discarded or given to someone else due to lack of labeling.

Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assessment and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) was utilized effectively for identifying and resolving deficiency related to timely complete residents' assessment for 13of 29 sampled residents (Residents 41, 44, 7, 87, 73, 14, 27, 55, 96, 100, 291, 293, and 294). This failure had the potential to inaccurately reflect the data relative to the residents' health status, and delay the developments of a comprehensive, individualized care plan for the residents.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to development and implement appropriate plans of action to correct identified deficiency related to infection control. As a result, deficient practices were present regarding infection control that had the potential to affect the safety and quality of care provided to residents. Refer to F 880.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection control practices when: 1. Facility staff did not perform hand hygiene during meal service. 2. Nursing unit resident nourishment rooms were not sanitary. (Refer to F812, F813, F925.) 3. Chemicals that were not food-safe were used to clean food contact surfaces in nursing unit nourishment rooms Refer to 812. 4. The RNA (Resource Nursing Assistant) Room was unsanitary and had live cockroaches. Refer to F925. 5. Resident 8's CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) and Nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask had white and brown spots throughout the masks and oxygen tubing on the floor where a bug was crawling. 6. [...]

Inspectors wroteBased on observation, interview, and facility review the facility failed to ensure they maintained an effective pest control program when: 1. An unidentified bug was seen crawling in resident room [ROOM NUMBER]. 2. Cockroaches were seen crawling around in the Restorative Nursing Assistant (RNA)room (the dining room that Residents eat in which includes a small kitchen area). This failure had the potential to cause a health hazard to the residents and did not honor their right for a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility to address resident's grievance of staff going through resident's personal belongings without resident's permission for one of eight sampled residents (Resident 183). This deficient practice had the potential for Resident 183's grievance to go unnoticed, causing anger and distress to the resident; and had the potential to result in a delay of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of transfer or discharge for one of three residents (Resident 292) (or resident representee, RP) was provided to Resident 292 and to the office of the State Long-Term Care (LTC) Ombudsman (a person who investigates and helps resolve complaints for residents) when they were sent to the hospital for emergency care. This failure had the potential to result in the lack of coordination of support for Resident 292 during discharge planning.

Inspectors wroteBased on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS, a standardized resident assessment) withing 92 days of the previous assessment for two of nine sampled residents (Resident 57 and 8). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 57 and Resident 8 related to the care areas identified on the MDS.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level 1 Preadmission Screening and Resident Interview (PASARR, an assessment that screened individuals with a mental disorder or intellectual disability to determine if admission to the facility was appropriate) was inaccurate for one out of three sampled residents (Resident 87) when: 1. The Level 1 PASARR was missing the diagnosis of bipolar (extreme mood swings). 2. The Level 1 PASARR included the diagnosis of dementia (memory loss). This failure had the potential for newly admitted residents to be admitted to the facility without knowing if they had a mental disorder or if the facility could provide services that met their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized patient-centered care plan for one of twenty-nine sampled residents (Resident 288) when: a care plan was not developed for significant weight loss for Resident 288. As a result, Resident 288, who was identified as malnourished at admission, had a weight loss of 11 pounds or 6.24 % in 2 weeks. This failure had the potential to contribute to the risk of further weight loss and decline for Resident 288.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one out of 32 sampled residents (Resident 73) with professional standards of care when Licensed Nurses (LN) utilized a DeClogger (a long, thin, flexible, piece of plastic with a jagged end that was used to de-clog peg-tubes) on Resident 73's peg-tube (a tube that was inserted into the abdomen and delivered liquid nutrition directly into the stomach). There was no Physician's order, no monitor in place that tracked how often LN utilized the DeClogger, and there was no care plan (a document that described the care a resident needed and how that care would be provided). This failure had the potential for peg-tube malfunctions to go unnoticed and could lead to a decline in resident health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate care was provided to prevent urinary tract infections (UTI's, a clinically detectable condition associated with invasion by disease causing microorganisms [germ] of some part of the urinary tract) for one of 29 sampled residents (Resident 44) when Certified Nursing Assistances did not do complete and proper peri-care (the process of washing the genital and anal areas) after incontinent episodes. This deficient practice had the potential to cause UTI's for incontinent residents and a decline in health status. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain the nutritional status for one of three sampled residents (Resident 288), when Resident 288 had insidious weight loss within a month timeframe (from 11/19/24 to 12/3/24). The weight loss was not identified, and intervention was not implemented. As a result, Resident 288, who was identified as malnourished at admission, had a weight loss of 11 pounds or 6.24 % in 2 weeks. This failure had the potential to contribute to the risk of further weight loss and decline for Resident 288.

Inspectors wroteBased on interview and record review the facility failed to provide necessary monitoring for one out of two sampled residents (Resident 87) while on an antipsychotic (a medication that altered the brain, caused a change in mood, awareness, thought, feelings, or behaviors) medication when: 1. Resident 87 was prescribed Asenapine (an antipsychotic medication that can be used to treat bipolar [a serious mental illness that caused mood swings] disorder) Transdermal Patch (a patched that was placed on the skin) and there was no monitor in place that tracked specific behaviors for the use of Asenapine. 2. Resident 87 was prescribed Haloperidol (Haldol, an antipsychotic medication that can be used to treat bipolar disorder) and there were no monitors in place that assessed for adverse reactions (side effects that could be serious or dangerous). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Registered Dietitian (RD) and Dietary Services Manager (DSM) provided adequate oversight of the Food and Nutrition Services (FNS) when 1. The RD did not provide evidence of regularly scheduled consultation and audits of the kitchen. 2. Effective systems and monitoring were not in place to ensure sanitation of the kitchen, food cooling, the consistency of pureed foods on tray line, and management of dented cans. 3. The facility accepted residents with requirements for Vegetarian diet, the RD and DSM reported the four-week vegetarian menu cycle and cook's spreadsheets had been in place for a while, but kitchen staff were not aware of a pre-planned vegetarian menu and did not follow it. [...]

Inspectors wroteBased on interview and record review, the facility failed to explain the terms of the arbitration agreement (arbitration: a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments.) to the resident in a language that the resident understood for one of five sampled residents (Resident 283). This failure resulted in Resident 283 signing a document that she did not understand and had the potential to result in Resident 283 to not be able to make an informed decision and/or her rights to be denied.

Inspectors wroteBased on interview and record review the facility failed to ensure pain medication was administered, in accordance with the resident ' s comprehensive care plan, and the resident ' s goals for care and preferences for one of three residents (Resident 1) who were sampled for pain management. This failure caused Resident 1 to experience increased pain and discomfort with the potential to experience a decline in her health condition.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 12 sampled residents (Resident 1) was free from mistreatment, misappropriation of property, and mental abuse when he was abducted (removed by force) from the facility by a restricted visitor (not authorized to visit or call). This resulted in Resident 1 to be taken out of the facility for 90 minutes with a restricted visitor who would attempt to financially abuse him. An Immediate Jeopardy (IJ) situation was identified on 7/19/24 at 3:45 pm, in the presence of the Executive Director (ED) and Director of Staff Development (DSD), due to not implementing a restricted visitor screening system that ensured residents were protected from any type of abuse from unauthorized visitors. An immediate jeopardy removal plan was requested from the ED and DSD. [...]

Inspectors wroteBased on in interview and record review the facility failed to provide residents food that is palatable (tasty, and flavorful) .,and an appetizing temperature for 12 of 23 residents (Residents: 101, 289, 57, 94, 66, 231, 230, 100, 52, 20, 44, 41) when residents complained of food regularly not tasting good and being cold. This failure had the potential to result in residents not obtaining appropriate nutritive intake, precarious weight loss, increased health complications, and diminished emotional well-being.

Inspectors wroteBased on interviews and record reviews the facility failed to notify the provider with the need to review and update the pain treatment plan for 1 of 5 residents (Resident 231), when Resident 231 had continuous pain at levels that indicated pain was not managed by the regimen ordered. This failure had the potential to result in decline of mobility, increased health complications, and diminished emotional well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that resident's pain was managed for 1 of 5 residents (Resident 231) when resident 231 Consistently reported pain levels of 4-9 regularly to staff, both prior to, and following pain medication administration, and new orders were not obtained for a more tolerable pain management regimen. This failure had the potential to result in a decline in mobility, increased health complications, and diminished emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control techniques were implemented when: 1. a vial of blood glucose test strips, that multiple residents use, was brought into Resident 94's room and was left uncapped and placed next to the used, blood-contaminated Glucometer (a device that uses an inserted test strip containing a small amount of blood applied to measure Blood Sugar levels) after testing Resident 94's blood sugar. 2. a used lancet (a small, sterile single-use needle used to draw a drop of blood for testing, as with a glucometer) was wrapped inside a used glove and placed in a trash can that was inside Resident's room. These failures had the potential for cross-contamination, needlestick injuries, and infection to occur. [...]

Inspectors wroteBased on interview, observation and record Review, this requirement was not met when staff caused pain and redness to a resident ' s foot, resulting in a delay in the progress toward his rehabilitation goals.