Complaint Investigation

Feather River Care Center

November 25, 2025 · Oroville, CA · 1 Gilmore Lane

Citations 1

CMS Rating 1/5

Beds 50

Provider ID 055612

Healthcare Facility

Feather River Care Center

Oroville, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

FEATHER RIVER CARE CENTER in OROVILLE, CA — inspection on November 25, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Potential for More Than Minimal Harm

During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] 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].

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.

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

Facility ID:

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.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.