Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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 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 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 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 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.
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.
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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 | — | 4 | 0 |
| Wolf Creek Care Center | 0.5 mi | — | 3 | 0 |
| Crystal Ridge Care Center | 0.6 mi | — | 2 | 0 |
| Westview Healthcare Center | 19.4 mi | — | 9 | 0 |
| Siena Skilled Nursing & Rehabilitation Center | 20.1 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.