Cass Valley Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cass Valley Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 25, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Aug 22, 2024

  Based 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. Findings include: Observation of Resident #22's video surveillance revealed CNA H assaulting the resident on three occasions during the 6:00 PM to 6:00 AM shift on 07/04/2024. […]

• Immediate jeopardy, isolatedF684Oct 19, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 19, 2023

  Based 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. […]