Feather River Care Center
Inspection Findings
F-Tag F0604
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 that one of six sampled residents (Resident 1) remained free from restraint when a staff member restrained Resident 1 upright in a wheelchair. This placed Resident 1 at increased risk for injury, accident, and negative health outcomes.Findings: During a
review of the facility policy titled, Restraint Free Environment, revised 2025, indicated the facility Prohibits
the use of physical restraint for discipline or staff convenience and limits restraint use to circumstances in which medical symptoms warrant the use of such restraints. The policy defined Physical restraint to include
the following example: Tucking in a sheet tightly so the resident cannot get out of bed . fastening fabric or clothing so that a resident's freedom of movement is restricted. The policy further clarified; Falls do not constitute . a medical symptom that warrants the use of physical restraints. During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses that included metabolic encephalopathy (brain dysfunction related to illness), pneumonia, and Chronic Obstructive Pulmonary Disease (difficulty breathing.) During a review of Resident 1's physician's order, dated 11/10/25, indicated that Resident 1 had capacity and could make his own medical decisions.During an interview on 11/25/25 at 10:40 am, with the DON (Director of Nurses,) the DON stated that the facility had confirmed that Certified Nurse Assistant (CNA) B had restrained Resident 1 on 11/16/25. DON stated CNA B had confirmed she tied Resident 1 to his chair with a sheet and asserted CNA B took this action at Resident 1's request. DON stated that CNA B had been immediately removed from patient care once the facility was notified of the accusation. The facility investigation confirmed that CNA B restrained the resident, and the facility is in the process of terminating the staff member. DON stated that no residents currently have an order for the use of restraints. DON stated that Resident 1 is no longer at the facility, Resident 1 was transferred on to the acute care hospital on [DATE REDACTED].During an interview on 11/25/25 at 12:35 pm, with the CNA B, CNA B confirmed that she had been working on 11/16/25 and had used a bed sheet to tie Resident 1 upright in a chair. CNA B confirmed she secured the bed sheet with a knot at the back of the chair, and that Resident 1 could not release himself. CNA B stated she did this at Resident 1's request but now realizes she should have refused. CNA B confirmed she had received training on resident abuse and restraints from the facility and as part of her CNA training.
Residents Affected - Few
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
Event ID:
FEATHER RIVER CARE CENTER in OROVILLE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OROVILLE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FEATHER RIVER CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.