Grass Valley Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 24, 2025

  Based 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. Findings: Resident 1 was admitted to the facility in the fall of 2025 with diagnoses which included traumatic brain injury (an injury to the brain caused by a sudden bump, or jolt to the head, which can disrupt its normal function), muscle weakness, and difficulty walking. […]

• No harm, potential for more than minimal, patternF679Sep 25, 2025

  Based 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.Findings:A review of Resident 17's clinical record indicated Resident 17 was admitted February of 2018 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), anxiety disorder (a mental health… […]

• No harm, potential for more than minimal, patternF803Sep 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Sep 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF880Sep 25, 2025

  Based 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. […]