Grass Valley Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to store items in a sanitary manner for two of six sampled residents (Resident 1 and Resident 2) when used urinals were stored uncovered in a drawer that contained the residents' personal items. This failure increased the risk of contamination and infection for the residents.

Inspectors wroteBased on interview and record review the facility failed to provide appropriate and adequate supervision to prevent an avoidable accident when one of three sampled residents (Resident 1) left the facility without the facility's knowledge and supervision. This failure resulted in Resident 1 experiencing falls outside the facility, leading to multiple abrasions on the hands and knee and increased the risk of cold exposure and potential injury from passing motor vehicles.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of 24 sampled resident (Resident 17) was provided with an ongoing activity program that meets psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs that are important to a person) when Resident 17's frequency of ongoing activity program visit was followed. These failures had the potential for Resident 17 to not achieve her highest mental, emotional, spiritual, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for therapeutic diets (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 9/22/25 and 9/23/25 when:1. Two residents (Resident 19 and 77) with CCHO (controlled carbohydrate) diets (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) received one slice of garlic bread instead of one half (1/2) slice.2. 22 residents (Resident 3, 5, 16, 22, 28, 32, 37, 38, 40, 47, 50, 62, 63, 65, 66, 67, 70, 74, 77, 81, and 96) with fortified diets (a dietary pattern that includes foods that have been enriched with additional nutrients, such as calories and protein) did not get the fortified foods.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when:1. The ice machine was not clean; and2. The arrangement of the food stored in the freezer was not in a food safety manner; and3. Items found in the clean and ready-to-use storage areas: A few metal sheet pans were stored and stacked wet; and The metal sheet pans, food processor and metal strainers were found with brown substances; and4. Three dietary staff did not wear hair restraint and beard restraint appropriately; and5. Three dietary staff did not practice hand hygiene between soiled and clean dishes during the dishwashing process; and6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 80 residents when:1. Enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use) was not implemented to Resident 5 and Resident 63;2. A facility staff did not wear required personal protective equipment (PPE) when performing resident care on Resident 56 who was on EBP; and,3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care for one out of 24 sampled residents (Resident 3), when Resident 3 did not receive treatments as ordered by the physician. This failure had the potential for Resident 3's wounds to not heal, put them at risk for further skin breakdown and not achieve their highest practicable well-being. Resident 3 was originally admitted to the facility in September 2024 with multiple diagnosis which included type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin) with foot ulcer (open sore on the foot) and cellulitis (bacterial infection of the deeper layers of the skin) of right lower limb. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 56) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 56's foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care and butterfly strap (a small, adhesive device designed to secure the catheter tubing to the skin, preventing accidental removal and reducing patient discomfort) monitoring was not done consistently. This failure had the potential for Resident 56 to develop infection and possible foley catheter dislodgement (removal) and/or other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 24 sampled residents (Resident 11) when Resident 11's oxygen saturation (percentage of oxygen carried in the blood) was not consistently monitored. This failure had the potential to result in Resident 11 developing respiratory issues without staff knowledge and for Resident 11 to not achieve her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 56) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 56's pain medication order was not consistently followed. This failure had the potential for Resident 56 to experience unrelieved pain and not attain her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure dental services were provided in accordance with professional standards of care for one out of 24 sampled residents (Resident 7), when facility staff did not assist Resident 7 in obtaining a dental appointment as physician ordered. This failure had the potential for Resident 7 to experience unnecessary pain and an increased risk for infection. Resident 7 was originally admitted to the facility in August 2024 with multiple diagnosis which included bacteremia (bacteria in the blood), depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities) and anemia (low levels of healthy red blood cells). A review of Resident 7's Minimum Data Set (MDS, an assessment tool) signed 6/27/25, indicated, Resident 7 had severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure special dietary requirements were met for two of 80 residents (Resident 22 and 42) during lunch meal observation on 9/22/25. This deficient practice had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of residents.

Inspectors wroteBased on interview and record review the facility failed to follow their pain management policies and procedures (P&P) for three out of three residents (Residents 1, 2, and 3) when: 1. Resident 1 had high PRN (as needed and must be asked for) pain medication usage for eight months prior to evaluating the need to change the current pain medication regimen. 2. The facility failed to determine if Resident 1's behavior of screaming was caused by pain, anxiety, or related to a diagnosis of dementia. 3a. Non-pharmacological interventions (any health intervention that was used to assist with managing chronic pain and did not involve the use of medication. Examples included but were not limited to distraction, music, re-positioning, stretching, or activities) were not implemented or monitored for effectiveness for Resident 1. 3b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident 1's rights were protected when:1. Licensed Nurse (LN) B administered a PPD test (purified protein derivative, injected under the skin to determine if a person had tuberculosis, a contagious bacterium that had the potential to cause death) after Resident 1's responsible party (RP, decision maker) had declined administration of the PPD test. 2. The facility provided medication to Resident 1 based on the RP's decisions rather than assessment data and concerns regarding Resident 1's appearance of being sedated. These failures violated Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to follow their policies and procedures (P&P) regarding medication administration documentation for one out of three sampled residents (Resident 1) when Licensed Nurse (LN) B initialed the medication administration record (MAR) for a medication that LN A prepared and administered to Resident 1. This caused inaccurate documentation and had the potential to negatively impact resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when facility staff disinfected the Hoyer lift (mechanical device used to safely transfer residents from one place to another) in the hallway, did not wear gloves, or perform hand hygiene (washing hands or using alcohol-based hand sanitizer) afterwards. This failure had the potential to spread infections to other residents, facility staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label/date and dispose of specific food in accordance with the professional standards for food service safety 2. Have dietary staff follow hygienic practices in the facility's kitchen 3. Have accurate values and documentation for the dish machine chemical solutions. These failures resulted in the potential to result in putting residents at risk for food borne illnesses (illness caused by consuming contaminated foods or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff with documentation that dietary staff had been provided appropriate competencies and trainings. This failure had the potential to result in dietary staff providing inadequate and potentially harmful services that could result in foodborne illnesses (illness caused by consuming contaminated foods or beverages).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 43) was free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions or behavior) when Resident received clonazepam (a type of medication used to treat anxiety, seizures and panic disorders) on an as needed (PRN) schedule for longer than the 14 day limit without clinical justification. This failure had the potential for adverse effects such as sedation, falls, headaches weight gain, dizziness, nausea and abnormal involuntary movements.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practices in one of four medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when undated multidose prescription medication was stored and available for use. These failed practices could contribute to unsafe medication storage and administration of outdated and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the physician ordered diet for one of eighteen sampled residents, (Resident 24) when the Fortified Regular, finger foods, small portions diet was not followed. This failure had the potential to cause negative clinical outcomes including weight loss, and the inability to eat independently due to a severe cognitive impairment.

Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to implement their policy and identify an allegation of resident to resident abuse for six residents (Resident (R) 43, R61, R44, R47, R20 and R63) out of a survey sample of 17 residents. Specifically, the facility failed to report allegations of resident to resident physical abuse, within 24 hours, to the State Agency (SA) as federally mandated. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 69 resident's residing in the facility at the time of the survey.

Inspectors wroteBased on interview, record review, the facility failed to ensure all allegations of suspected abuse were reported immediately, but not later than 24 hours after the allegation was made, for resident to resident altercations which involved six residents (Resident (R) 43, R61, R44, R47, R20 and R63). This failure had the potential to impede the safety and protection of the facility's residents.