Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grass Valley Healthcare Center during CMS and state inspections, most recent first.
Two residents with histories of urinary tract infections had uncovered urinals stored in drawers alongside personal care items such as toothbrushes, cups, and medical equipment. Staff and infection prevention personnel confirmed that urinals should be stored separately to prevent contamination, in accordance with facility policy.
A resident with TBI, muscle weakness, difficulty walking, intermittent confusion, and impaired decision-making left the facility without staff knowledge or supervision. Staff later found him wet, cold, confused, and unsteady after he reported several falls while walking, and records documented abrasions to his hand, knee, foot, and toe. The DON stated the expectation was to keep residents safe, and the facility policy identified resident safety and supervision as facility-wide priorities.
Multiple residents did not receive meals according to their prescribed therapeutic diets, including incorrect bread portions for those on CCHO diets, missing fortified foods for those on fortified diets, and improper food textures and portion sizes for those on puree and half-portion diets. These deficiencies were confirmed by the registered dietitian and observed during meal service.
A resident with dementia, anxiety disorder, and severe cognitive impairment did not receive the planned ongoing activity program frequency or preferred activity materials. Care plan documentation called for 1:1 room visits and activity staff visits 3 times weekly, but records showed inconsistent visits over several months, and observations found the resident in bed with the TV off and no radio, music, books, newspapers, or magazines present. The AD confirmed there were no documented refusals, and the DON and DSD stated they expected the activity plan and resident preferences to be followed.
Food service safety practices were not followed in several kitchen areas. An ice machine had black residue on internal components, frozen foods were stored with raw meats and ready-to-eat items in the wrong order, clean storage held wet pans and equipment with brown residue, dietary staff were observed without proper hair and beard restraints, three staff did not wash hands between soiled and clean dish tasks, and a can opener blade had chipped coating.
Failure to Follow EBP and Contact Precaution PPE Requirements: A resident with a wound and another resident with an arterial foot wound were not placed on EBP, and staff provided care using gloves only during linen changes, transfers, toileting, dressing, and wound care. A resident with an indwelling catheter on EBP also had personal care performed without a gown, and a CNA entered a contact precaution room for a resident with MSSA pneumonia without gown or gloves. The IP and DON confirmed the facility’s PPE expectations, and staff acknowledged the missed PPE use.
A resident with severe cognitive impairment and multiple medical conditions was not assisted in obtaining a dental appointment after a physician ordered a dental referral for pain. The Social Services Director, responsible for scheduling such referrals, was unaware of the order and did not arrange the appointment, resulting in the resident not receiving timely dental care.
A resident with DM2, a foot ulcer, and cellulitis had ordered wound care for a left medial ankle wound and A&D ointment for coccyx dry skin, but the MAR showed the treatments were missed on multiple occasions. The IP confirmed the ordered treatments were not completed as prescribed, and the facility job description stated the Medication Nurse is responsible for providing care as prescribed by the physician.
Inconsistent Foley catheter care and securement monitoring were identified for a resident with neurogenic bladder and an indwelling catheter. The resident’s order required catheter care and butterfly strap placement checks every shift, but TAR review showed multiple missed entries across several shifts. LN confirmed the care was not consistently done, and the DON and DSD stated staff were expected to follow the order to help prevent infection and catheter displacement.
Inconsistent O2 Saturation Monitoring for Resident on Oxygen Therapy: A resident with COPD and CHF was receiving O2 at 2 L/min via NC with an order to maintain O2 saturation above 92% and to monitor every shift. Record review showed multiple missed O2 saturation checks across several shifts, including night and evening shifts. An LPN confirmed the monitoring was not consistently completed, and the DON and DSD stated that O2 saturation monitoring was expected and important, especially at night.
A resident with a left thigh fracture and cardiomyopathy had moderately impaired cognition and reported needing to ask for pain medication. The physician ordered morphine sulfate oral solution at different doses based on pain level, but MAR review showed the lower dose was given on occasions when the documented pain level was 4. An LPN confirmed the order was not consistently followed, and the DSD and DON stated the resident should have received the higher ordered dose for those pain levels.
Failure to Follow Meal Ticket Dietary Preferences: Two residents did not receive meals consistent with their documented food preferences during a lunch meal observation. One resident did not receive vegetable juice listed on the meal ticket, and another resident received pepper and non-salt seasoning despite the ticket stating no pepper and no non-salt seasoning. The RD stated staff needed to follow the meal ticket to meet and honor resident preferences.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
A licensed nurse initialed the MAR for a medication that was administered by another nurse, contrary to facility policy requiring the administering nurse to document medication administration. This resulted in inaccurate documentation for a resident with multiple medical conditions, as confirmed by the DON.
Two CNAs cleaned a Hoyer lift in the hallway without wearing gloves or performing hand hygiene after using CaviWipes, then entered a resident's room with the equipment. Both CNAs acknowledged not following facility policy, and the infection preventionist confirmed that proper PPE and hand hygiene were required but not used.
Improper Storage of Urinals with Personal Items
Penalty
Summary
The facility failed to store toileting items, specifically urinals, in a sanitary manner for two residents. For one resident, an uncovered urinal was found in a closet drawer alongside a clear drinking cup holding an uncovered toothbrush and a bottle of cologne. For the second resident, an uncovered urinal was stored in a closet drawer with a blood pressure cuff, a red plastic dining place mat, and a seat cushion. These observations were confirmed by the Infection Preventionist, who stated that urinals should not be stored with personal care items for infection control reasons. Both residents had medical histories that included urinary tract infections, and one also had a diagnosis of bacteria in the bloodstream. Interviews with staff, including a CNA and the DON, confirmed that the expectation was for urinals to be stored separately from other personal items to prevent contamination and infection. Review of the facility's policy indicated that toileting items, including urinals, should be stored separately from other personal items to prevent infections.
Failure to Supervise Resident Who Left Facility Unnoticed
Penalty
Summary
The facility failed to provide appropriate and adequate supervision to prevent an avoidable accident when one resident left the facility without the facility's knowledge or supervision. The resident was admitted in the fall of 2025 with diagnoses including traumatic brain injury, muscle weakness, and difficulty walking. His MDS dated 11/6/25 indicated moderate memory impairment and independence with most ADLs. A fall risk evaluation dated 10/30/25 indicated intermittent confusion, and a wandering risk assessment dated 11/3/25 indicated the resident lacked capacity to understand and make decisions and was at low to moderate risk of elopement. According to progress notes, staff discovered the resident missing during rounds when a CNA identified him as absent from his room, with the last visual check documented at 3:30 a.m. Staff followed the missing resident protocol without success, and the resident was later located by staff members and a family member around 8:15 a.m. The resident stated he left the facility around 4:00 a.m. and had several falls while walking. The discharge instruction form documented abrasions to the right hand, scrape to the right knee, an outside area of the right foot, and a reddened area to the left great toe. Staff interviews stated he returned soaking wet, very cold, confused, and unsteady, with fresh scratches on his hand and knee. The DON stated the expectation was to keep residents safe, and the facility policy identified resident safety and supervision as facility-wide priorities.
Failure to Follow Prescribed Therapeutic Diets and Menu Portions
Penalty
Summary
The facility failed to ensure that prescribed therapeutic diets were followed as indicated on the approved menus for multiple residents. During lunch meal observations, two residents on controlled carbohydrate (CCHO) diets received a full slice of garlic bread instead of the prescribed half slice, as confirmed by both menu documentation and the registered dietitian. Additionally, 22 residents on fortified diets did not receive the required extra melted margarine and salad dressing, which were specified on the fortified menu to provide additional calories for those at risk of weight loss. The registered dietitian confirmed that these fortified foods were not provided as required. Further deficiencies were observed when two residents with puree diet orders were served mashed potatoes instead of the prescribed pureed red beans and rice, as indicated on the menu for that meal. Additionally, two residents with orders for half portion sizes were instead served small portion sizes, with the dietary supervisor incorrectly equating the two. The registered dietitian clarified that half portions should be exactly half of the regular portion, and noted that only verbal in-services had been conducted regarding portion sizes, with no formal training or policy in place. The facility's policy required adherence to prepared menus and portion control guides, but these were not followed during the observed meals.
Failure to Provide Planned Activity Program Visits and Preferred Materials
Penalty
Summary
The facility failed to ensure that Resident 17 received an ongoing activity program that met her psychosocial needs when the planned frequency of activity visits was not followed. Resident 17 was admitted in February 2018 and had diagnoses including dementia, anxiety disorder, skin cancer, and muscle weakness. Her MDS indicated severely impaired cognition with a BIMS score of 2 out of 15. Her annual MDS preferences showed it was very important for her to listen to music she likes and do her favorite activities, and somewhat important for her to have books, newspapers, and magazines to read. Resident 17’s care plan stated that she chose not to attend activities, was mostly bed bound, and received 1:1 room visits. Another care plan goal stated that activities would visit 3 times a week through the review date, and the intervention directed the activity department to supply materials, audio, visual, and entertainment as needed per preferences. However, progress notes showed activity staff visited only once in June 2025, three times in July 2025, four times in August 2025, and three times in September 2025 as of 9/24/25. During a concurrent interview and record review, the Activities Director confirmed that the frequency of ongoing activity program visits was followed and that there were no documented refusals. Observations in Resident 17’s room on 9/22/25, 9/23/25, and 9/24/25 showed her lying in bed with the television off and no radio, music devices, books, newspapers, or magazines present. The AD stated she would expect staff to follow the planned activity frequency and preferences because of the risk of decline in quality of life and activities if the plan was not followed. The DSD and DON also stated they expected residents’ ongoing activity program frequency, preferences, and care plans to be followed because of isolation and well-being concerns. The facility policy stated the activities program is intended to support resident well-being, is based on resident-centered assessment and preferences, and includes individual activities designed to meet each resident’s needs and interests.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
Food service safety practices were not followed in multiple areas of the kitchen and dish room. During observation, the ice machine was found with black substances at the bottom of the evaporator after the removable trough was taken out. The Dietary Supervisor confirmed the substance was present and stated the area could not be reached or cleaned, while the Registered Dietitian confirmed the monthly cleaning had missed that area. The facility policy required the internal components of the ice machine to be cleaned monthly. Frozen food was also stored in an improper arrangement in the reach-in freezer. Ready-to-eat items such as garlic bread, hash browns, diced cooked ham, and mac and cheese cups were stored alongside raw meats, including beef patties, raw beef, raw ground beef, and pork items, on shelves labeled for different food categories. The Dietary Supervisor stated she was not aware of the proper hierarchy for food storage and agreed that ready-to-eat foods should be stored above raw meat. The Registered Dietitian stated the freezer storage should follow the facility’s food storage guidelines, which required raw meat, poultry, and fish to be stored separately from cooked and ready-to-eat foods and in order by required cooking temperature. Clean and ready-to-use storage areas contained equipment that was not clean or dry. Several metal sheet pans and a metal strainer had brown substances on them, a food processor bowl had brown substances, and multiple sheet pans were wet when stored. The Dietary Supervisor identified the brown substances as food particles and stated pans and equipment should be clean and air-dried before storage. In addition, dietary staff were observed without proper hair or beard restraints, including staff with exposed facial hair and hair not fully contained, and three dietary staff did not perform hand hygiene between handling soiled and clean dishes during dishwashing. The can opener blade was also observed with chipped and discolored metal coating, and the Dietary Supervisor stated it needed replacement. The facility policies cited in the report required proper storage, sanitation, handwashing, dress code compliance, and maintenance of the can opener.
Failure to Follow EBP and Contact Precaution PPE Requirements
Penalty
Summary
The facility failed to provide and implement an effective infection prevention and control program when enhanced barrier precautions were not implemented for two residents with wounds and when staff did not use the required PPE during resident care. Resident 5 was admitted with diagnoses including a right heel pressure ulcer and sepsis due to MSSA. His MDS indicated moderately impaired cognition and two unstageable pressure ulcers present on admission. During observation, a CNA changed Resident 5’s linens and transferred him to bed using only gloves, and later a TN performed wound care and dressing change on his right foot wounds while only wearing gloves. The IP also assisted with holding the resident’s foot for wound photo and measurement while only wearing gloves. The CNA and TN confirmed the observations, and the IP stated Resident 5 was not on EBP because the wound was progressing. Resident 63 was admitted with diagnoses including diabetes mellitus, PVD, and need for assistance with personal care. His MDS showed intact cognition, and his skin and wound evaluation documented an arterial wound on the right foot acquired in the facility. During observation, a CNA assisted Resident 63 with morning care, toileting, changing briefs, dressing, and transferring him to a wheelchair while only wearing gloves. LN 4 stated the resident had previously been on contact precaution because of the wound but was not on EBP. The facility’s precaution list showed Resident 63 was not on EBP or any transmission-based precaution, and the IP stated the facility used EBP only if a wound was not progressing within 30 days. The facility also failed to follow PPE requirements for residents on precautions. Resident 56 had an indwelling catheter and was on EBP, with signage posted at the room entrance, an active physician order for EBP due to indwelling catheter, and a care plan directing staff to use gowns and gloves for all personal care. During observation, a CNA changed Resident 56’s shirt and pants while wearing gloves only and no gown, and the CNA stated staff usually wore gown and gloves when dealing with the catheter but not when changing her. In another instance, Resident 18 was on contact precautions for MSSA pneumonia, with signage at the room entrance directing staff to wear gown and gloves. Despite this, a CNA entered the room without gown or gloves and delivered the resident’s lunch tray. The CNA acknowledged not wearing PPE, and the IP confirmed that staff and visitors were expected to wear gown and gloves when entering contact precaution rooms.
Failure to Assist Resident with Physician-Ordered Dental Referral
Penalty
Summary
Facility staff failed to provide dental services in accordance with professional standards of care for one resident. The resident, who was admitted with multiple diagnoses including bacteremia, depression, anemia, and severe cognitive impairment, had a physician order for a dental referral due to dental pain. Despite this order, the resident was not assisted in obtaining a dental appointment as required. The Social Services Director, responsible for ensuring dental referrals are scheduled, confirmed during interview and record review that she was unaware of the referral and did not schedule the appointment. A review of the facility's policies indicated that social services staff are responsible for assisting residents in accessing and scheduling dental services. The failure to follow these procedures resulted in the resident not being seen by a dentist after the referral order was made. The deficiency was identified through interviews, record reviews, and policy examination, confirming that the required dental care was not provided as ordered.
Physician-Ordered Wound and Skin Treatments Not Completed
Penalty
Summary
The facility failed to ensure physician orders were followed for one sampled resident who was cognitively intact and had been admitted with multiple diagnoses including type 2 diabetes mellitus, a foot ulcer, and cellulitis of the right lower limb. The resident had an order for treatment of a left medial ankle wound that included cleansing with normal saline, applying calmoseptine to the peri-wound skin, applying Medi honey to the wound bed, covering with a 4x4, and wrapping with kerlix and ACE bandage on specified days. The Medication Administration Record showed that the left medial ankle wound treatment was not completed as ordered on one date in September 2025. The resident also had an order for dry skin to the coccyx to receive A&D ointment every day and evening shift to maintain skin integrity and evaluate the need to continue or change the treatment. The MAR showed that the coccyx treatment was not completed as ordered on four dates in September 2025. During a concurrent interview and record review, the Infection Preventionist confirmed the treatment orders were not done as ordered on the identified dates and stated the expectation was for nursing staff to follow physician orders. The facility job description for the Medication Nurse stated the primary function was to ensure effective nursing care is provided as prescribed by the physician and to perform treatments according to physician orders.
Inconsistent Foley Catheter Care and Securement Monitoring
Penalty
Summary
Resident 56, who was admitted in June 2025 with diagnoses including neuromuscular dysfunction of the bladder and a left thigh fracture, had an indwelling Foley catheter and a care plan addressing the catheter due to neurogenic bladder. The resident’s MDS dated 9/9/25 indicated a BIMS score of 9 out of 15, showing moderately impaired cognition, and also documented an indwelling catheter. On 9/22/25, the resident was observed in the room connected to urinary catheter tubing and a bag draining cloudy, deep yellow urine, with the bag covered by a privacy bag and hung at the bedside. The physician’s order dated 6/17/25 required indwelling bladder catheter care every shift and monitoring of the catheter butterfly strap placement every shift. Review of the TAR for July, August, and September 2025 showed missed documentation for catheter care and butterfly strap placement monitoring on multiple shifts, including 7/3/25, 7/17/25, 8/28/25, 9/8/25, and 9/11/25. During interview and record review, LN 2 confirmed the care and monitoring were not consistently done and stated that if it was not charted, it was not done. The DSD and DON stated nurses were expected to follow the physician’s orders for catheter care and strap placement monitoring every shift, and the facility’s catheter care policy stated the purpose was to prevent catheter-associated complications, including UTIs, and to ensure the catheter remained secured with a securement device.
Inconsistent O2 Saturation Monitoring for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and proper delivery of respiratory care for one resident who was admitted in January 2024 with diagnoses including COPD and CHF. The resident’s MDS dated 7/7/25 indicated intact cognition with a BIMS score of 15/15 and that she was receiving oxygen therapy in the facility. Her care plan identified oxygen therapy related to decreased O2 saturation/congestion, included an intervention to check O2 sats, and her active physician order dated 12/3/24 directed oxygen at 2 L/min via nasal cannula to maintain O2 saturation greater than 92% with oxygen every shift. During observation on 9/23/25, the resident was awake, sitting in her wheelchair, and receiving oxygen via nasal cannula at 2 LPM. She stated she was always on oxygen because she had trouble breathing most of the time and that staff usually monitored her oxygen level. Review of the TAR for August and September 2025 showed multiple shifts when O2 saturation was not monitored, including several night shifts and one evening shift. A nurse confirmed the monitoring was not consistently done and stated it should have been checked every shift to ensure the resident’s O2 saturation remained above the ordered level. The DSD and DON also stated that oxygen saturation monitoring was important and expected to be done as ordered.
Inconsistent administration of ordered morphine for resident pain
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for one resident with a left thigh fracture and cardiomyopathy. The resident’s MDS indicated moderately impaired cognition and that she occasionally experienced pain and had received scheduled and as needed pain medications and non-medication interventions. During interview, the resident stated she usually experienced pain and had to ask the nurse for pain medication, and she was not sure if she was getting the right pain medication. The resident’s physician ordered morphine sulfate oral solution 20 mg/mL at two different doses based on pain level: 0.25 mL for pain rated 1-3 and 0.5 mL for pain rated 4-10. Review of the MAR showed the resident received the 0.25 mL dose on three occasions when the documented pain level was 4. During record review and interview, LN 2 confirmed the pain medication order was not consistently followed and stated there was no documentation that the resident’s responsible party requested the lower dose on those occasions. LN 2, the DSD, and the DON all stated the resident should have received the 0.5 mL dose for those pain levels, and the facility’s P&P required medications to be administered as ordered.
Failure to Follow Meal Ticket Dietary Preferences
Penalty
Summary
The facility failed to ensure special dietary requirements were met for two residents during the lunch meal observation in the dining room. Resident 22's meal ticket listed 0.8 ounces of vegetable juice as a food preference, but the resident did not receive the vegetable juice with the meal. Resident 42's meal ticket listed no pepper and no non-salt seasoning, but the resident received pepper and non-salt seasoning packets with the meal. During the meal observation, the resident's family member stated Resident 22 usually received vegetable juice but did not get one that day. A CNA confirmed that Resident 42's meal ticket indicated no pepper and no non-salt seasoning and stated those packets should not have been on the meal tray. The RD stated staff needed to follow the meal ticket to meet and honor residents' preferences. Facility policy stated the Food and Nutrition Service Director should check trays to ensure diets are served as ordered and visit residents to determine food acceptance and preferences, and the Food Preferences policy stated residents' food preferences would be adhered to within reason.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Inaccurate Medication Administration Documentation by Nursing Staff
Penalty
Summary
A deficiency occurred when a licensed nurse (LN B) initialed the medication administration record (MAR) for a medication that was actually prepared and administered to a resident by another licensed nurse (LN A). According to the facility's policy and procedure for administering medications, the individual who administers the medication is required to initial the MAR on the appropriate line after giving each medication and before administering the next dose. However, LN B confirmed during an interview and record review that she checked off the administration of oxycodone for the resident, despite not being the one who gave the medication. The resident involved had a medical history that included an unstageable pressure ulcer of the sacral region, depression, and dementia, and was not their own responsible party. The Director of Nurses (DON) confirmed that nurses should not sign out medication they did not administer. This failure to follow established medication administration documentation procedures resulted in inaccurate records for the resident.
Failure to Follow Infection Control Protocols During Equipment Cleaning
Penalty
Summary
Facility staff failed to follow infection control practices when two Certified Nurse Assistants (CNAs) disinfected a Hoyer lift in the hallway without wearing gloves and did not perform hand hygiene after cleaning the equipment. The CNAs used CaviWipes, a disinfectant that, according to its safety data sheet and facility policy, requires the use of gloves due to the risk of skin irritation and potential for infection transmission. After cleaning, the CNAs immediately entered a resident's room with the Hoyer lift without washing their hands or using hand sanitizer. Interviews with the CNAs confirmed that they were aware gloves should have been worn and hand hygiene performed after cleaning the equipment. The facility's infection preventionist also confirmed that the Hoyer lift should have been cleaned in the resident's room, not in the hallway, and that proper personal protective equipment and hand hygiene protocols were not followed during the observed incident. Facility policies reviewed indicated clear requirements for cleaning and disinfecting equipment, use of PPE, and hand hygiene, which were not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Grass Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Empire | 0 mi | ★★★★★ | 7 | 0 |
| Wolf Creek Care Center | 0.5 mi | ★★★★★ | 3 | 0 |
| Crystal Ridge Care Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Westview Healthcare Center | 19.4 mi | ★★★★★ | 42 | 0 |
| Siena Skilled Nursing & Rehabilitation Center | 20.1 mi | ★★★★★ | 2 | 0 |
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