Cass Valley Healthcare Center

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure a resident was free from verbal and physical abuse by staff for 1 of 4 sample residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse on 03/13/2026 when CNA A physically and verbally abused Resident #1 during care. This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of eight residents (Resident # 5, and Resident #18) reviewed for activities. The facility failed to provide Resident #5, and Resident #18 in room activities on the dates of 09/01/2025 thru 09/21/2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary [NAME] changed her gloves during food preparation after wiping her nose with her fingers on her left hand. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (Resident #5 and Resident #18) of 6 residents reviewed for comprehensive care plans. The facility failed to update Resident #5's and Resident #18's care plan to reflect current activity needs for in-room activities. This failure could place residents at risk of not receiving necessary services or having important needs identified and met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for 1 (Resident # 5) of 30 residents reviewed for medication storage and labeling The facility failed to ensure medication for Resident # 5 was stored and labeled as it was received. The facility failed to ensure that expired medication package was destroyed or sent back to the pharmacy. These failures could place the residents at risk for receiving the wrong medication or not receiving the therapeutic effect of the prescribed medication.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each residents' environment remained free of accident hazards for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure CNA A did not unlock the wheels and move Resident #1's bed during peri care, causing Resident #1 to fall. This resulted in Resident #1 being sent to the hospital with fractures and lacerations. An Immediate Jeopardy (IJ) existed from 05/31/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This failure could result in residents experiencing accidents, injuries, and diminished quality of life.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #1) The facility failed to make arrangements for a safe discharge for Resident #1. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 6 residents (Resident #1) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's urinal was emptied appropriately on 09/04/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #22) of 4 residents reviewed for abuse. The facility failed to prevent physical abuse against Resident #22 by CNA H as seen on video surveillance. The noncompliance was identified as PNC IJ. The IJ began on 07/04/2024 and ended on 07/05/2024. The facility had corrected the noncompliance before the survey began. This failure placed the resident at risk of physical and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the communication system which allows residents to call for staff assistance was within reach for 5 (Resident #4, Resident # 21, Resident # 31, Resident #26, and Resident #20) out of 17 residents reviewed for call system placement. The facility failed to ensure Resident #4, Resident #21, Resident #31, Resident #26 and Resident #20's call light was within reach. The failure could place residents at risk for being unable to call for assistance from staff.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 of 8 (Resident #12, Resident #18, Resident #25, and Resident #28) residents reviewed for ADL care. 1. The facility failed to ensure Resident # 12, Resident #18, Resident #25, and Resident #28 nails were cleaned and did not have any rough edges. These failures placed residents at risk of a decline in their hygiene, loss of dignity and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored, individual activities, independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident , encouraging both independence and interaction in the community for 3 of 8 residents ( Resident #10, Resident #19, and Resident #25) reviewed for activities. The facility failed to develop an activity program based on preferences of Resident #10, Resident #19, Resident #25 during the months of July to August 2024. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to appropriately thaw frozen meant defrost on 08/20/2024. 2. The facility failed to store boxes of food off the floor, ensure the floor of the refrigerator was free of debris in the walk- in refrigerator on 08/20/2024. 3. The facility failed to ensure Dietary Aide P washed or sanitized her hands prior to placing new gloves on her hands when she was giving a resident some zip lock bags on 08/21/2024. These failures placed residents at risk for health complications and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection and prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #1, Resident #11, Resident #28, Resident #4, and Resident #17) of 35 residents reviewed for infection control. 1. LVN B failed to clean the reusable blood pressure (BP) cuff between resident use. 2. LVN A failed to perform hand hygiene and clean the catheter tip before performing catheter irrigation for Resident #17's suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 5 residents (Resident #4, Resident #14, Resident #31, Resident # 9, and Resident #8) out of 10 resident rooms reviewed for environment. The facility failed to ensure walls and floors were clean and in good repair for Resident # 4, Resident #14, Resident #31, Resident #9, and Resident #8's room. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infections for 19 out 19. residents (Residents #1 - #19). The facility failed to: 1. ensure staff donned/doffed PPE/outside/inside rooms for residents on transmission-based precautions. 2. ensure staff wore the proper PPE inside the rooms for residents on transmission-based precautions. 3. ensure the facility had the proper PPE outside the rooms for residents on transmission-based precautions. On 12/22/23 at 6:13 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of five residents reviewed for quality of care. The facility failed to assess and obtain x-ray when Resident #1 began complaining acute pain and her knee/leg was broken in her left leg. The facility failed to order x-ray on 09/18/2023. An Immediate Jeopardy (IJ) situation was identified and on 09/21/2023 and Immediate Jeopardy template was presented to the facility on [DATE] at 3:37 PM. While the IJ was removed on 09/23/2023 the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of five residents (Resident #1) reviewed for injuries and supervision. The facility failed to ensure staff properly transferred Resident #1 from her wheelchair to her bed resulting in a fractured left leg causing severe pain. An Immediate Jeopardy (IJ) situation was identified 4:37 PM and on 10/18/2023 at and Immediate Jeopardy template was presented to the facility on [DATE] at 4:39 PM. While the IJ was removed on 10/19/2023 at the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life.

Inspectors wroteBased on observation and record review the facility failed to ensure residents were free from physical and verbal abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was protected verbal abuse on 09/18/2023 when CNA H made a derogatory comment regarding Resident #1 within earshot of Resident #1 and failed to assess Resident #1's pain before adjusting her swollen leg. This failure could place residents at risk for injury, mental anguish, depression, intimidation, and a diminished quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse/neglect of residents for one Resident #1) of three residents reviewed for abuse and neglect. The facility failed to implement their abuse/neglect policy when LVN A was notified of Resident #1's pain and the administrator was notified of the incident by the COTAand the administrator failed to investigate the injury per policy. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain in that: The facility failed to properly assess or provide effective pain management to Resident #1 after a new onset of pain following the accidental fracture of her left tibia during a transfer from wheelchair to her bed. This failure could place residents at risk of not receiving the highest practicable care through resident assessments by recognizing and addressing the physical dysfunctions in an effective and timely manner to prevent residents from further harm, injury, or death

Inspectors wroteBased on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs as identified through resident assessments and described in the plan of care for one of one resident (Resident #1) one of one nurses and one of one COTA reviewed for competent nursing staff. The facility failed to ensure nursing staff were properly trained and nursing staff failed to report to management when the nurse gave the COTA a pain pill to administer to Resident #1. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 9 (RN coverage days) of 101 days reviewed for RN coverage. The ADON/Staffing Coordinator failed to have an effective documentation and tracking system and was unaware of which RN's worked when she reviewed the schedule sheets and based on the timesheets, there was not 8 hours of RN Coverage on: 05/13/23, 05/14/23, 05/29/23, 06/11/23, 06/22/23, 07/06/23, 07/07/23, 07/09/23 and 07/10/23. These failures could place all residents at risk of not having an adequate amount of higher level nursing services which could result in a decline in the residents mental, physical and psycho-social well-being.

Inspectors wroteBased on interview, and record review, the facility failed to implement comprehensive care plans that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one (Resident #27) of three residents reviewed for care plans. The facility failed to implement a comprehensive care plan for Resident #27. This failure could place residents at risk of not meeting their immediate needs, long term and or short-term goals, and and interventions.

Inspectors wroteBased on Interviews and record review the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the category of work for each person on direct care staff for 1 (facility) of 1 facility reviewed for PBJ Data submissions. The facility failed to ensure the PBJ staffing Data submitted to CMS was accurate on 05/15/23, which showed the facility had low levels of RN and DON staff hours for the 2nd quarter of the 2023 fiscal year. This failure could place residents at risk of not having adequate staffing coverage based on the facility's census which could result in inadequate care, decreased physical, mental and psycho-social well-being.