Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wolf Creek Care Center during CMS and state inspections, most recent first.
A resident with TBI and cognitive deficits, whose responsible party had previously declined COVID-19 vaccination and whose refusal was documented, was later given a COVID-19 vaccine without informed consent. Progress notes showed the RP’s refusal followed by documentation that the vaccine was administered, and the responsible party discovered the vaccination after noticing a bandage on the resident’s arm and being told by nursing staff that the shot had been given. Facility records and administrator notes indicated that an LN acknowledged being responsible for administering the vaccine without consent, contrary to facility policy requiring informed consent and honoring the legal representative’s right to refuse treatment.
Two residents experienced significant safety failures: one with cognitive impairment was able to remove a Wander Guard and leave the facility unsupervised, while another, who used a wheelchair, was not properly secured during van transport and suffered a femur fracture requiring surgery. Staff interviews and records confirmed that required safety protocols and interventions were not effectively implemented or maintained.
A resident with a history of intracerebral hemorrhage and severe cognitive impairment was administered both Heparin and Aspirin despite a severe drug interaction warning. Nursing staff and the DON acknowledged awareness of the interaction and the resident's diagnosis but did not clarify the orders with the provider as required by facility policy. The pharmacist confirmed the medications were contraindicated and should have been clarified before administration.
COVID-19 Vaccine Administered Without Required Consent
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent for administration of a COVID-19 vaccine to a resident whose responsible party (RP) had previously declined vaccination. The resident, admitted with diagnoses including traumatic brain injury and cognitive deficit affecting decision-making ability, had an RP who was documented in a progress note dated 4/30/21 as having declined the COVID-19 vaccine after speaking with a licensed nurse (LN 3). The facility’s COVID-19 vaccine policy stated that residents or their legal representatives have the right to accept or refuse the vaccine, that informed consent must be obtained, and that refusals must be documented in the medical record. Despite the documented refusal, a subsequent progress note dated 5/4/21 indicated that the resident received a COVID-19 vaccine that morning. The RP later reported that the resident returned from a physician’s appointment with a bandage on his arm and stated he had been given a COVID-19 vaccine, and that an unidentified nurse acknowledged and apologized that the vaccine had been administered. Email correspondence from the current Administrator, referencing notes from the previous Administrator, indicated that the vaccine had been given without consent from the RP, and that LN 4 stated she was responsible for the vaccine being administered without consent from either the RP or the resident. This sequence of events resulted in the resident receiving a COVID-19 vaccine contrary to the RP’s documented refusal and without required informed consent, in violation of the resident’s RP’s right to make health care decisions.
Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure resident safety and prevent accidents for two residents. One resident, who had diagnoses including dementia, bipolar disorder, and generalized anxiety disorder, was identified as being at risk for elopement and had a Wander Guard device ordered and care planned to prevent unsupervised exit. Despite these interventions, the resident was able to remove the Wander Guard multiple times and ultimately left the facility without staff knowledge. The resident was found off facility grounds at a nearby gas station without the Wander Guard, and staff interviews confirmed that the resident had a history of removing the device and that the device's placement was not changed to prevent removal. Another resident, with diagnoses including parkinsonism, hemiplegia, and hemiparesis, and who used a wheelchair for mobility, experienced an avoidable fall during transportation to a medical appointment. The resident was cognitively intact and reported that the wheelchair was not properly secured in the van, despite notifying the driver twice. The driver failed to ensure the resident was properly fastened using the required seatbelt and four anchors, as per training and facility policy. Upon arrival at the destination, the resident fell out of the wheelchair inside the van, resulting in a left femur fracture that required surgery. Staff interviews and documentation confirmed that the driver had been trained on proper safety protocols but did not follow them during this incident. Facility policies reviewed indicated that resident safety and supervision are priorities, with ongoing identification of safety risks and environmental hazards, and that employees are to be trained to prevent avoidable accidents. The policies also specified interventions for residents at risk of wandering and elopement. In both cases, the facility did not implement or maintain effective interventions to prevent the identified hazards, resulting in one resident eloping and another sustaining a serious injury during transport.
Failure to Clarify and Prevent Administration of Contraindicated Medications
Penalty
Summary
The facility failed to follow its own policy and procedures and did not ensure professional standards of practice were met when a resident with a diagnosis of nontraumatic intracerebral hemorrhage (ICH), hemiplegia, transient ischemic attack, and cerebral infarction was administered medications with known severe drug interactions. Specifically, the resident was given both Heparin and Aspirin, which triggered a drug interaction warning in the medication system due to the risk of enhanced anticoagulant effects. The medication administration record confirmed that both medications were administered on the same day, despite the presence of a severe interaction warning. Interviews with licensed nurses and the Director of Nursing revealed that staff were aware of the resident's diagnosis and the drug interaction warning but did not clarify the orders with the physician as required by facility policy. The pharmacist confirmed that the combination of Aspirin and Heparin is contraindicated in such cases and should have been clarified with the provider. The facility's policy states that any medication order believed to be inappropriate or associated with potential adverse consequences must be discussed with the attending physician or medical director, which was not done 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 | 0.5 mi | — | 4 | 0 |
| Grass Valley Healthcare Center | 0.5 mi | — | 44 | 0 |
| Crystal Ridge Care Center | 1.1 mi | — | 2 | 0 |
| Westview Healthcare Center | 19.3 mi | — | 9 | 0 |
| Siena Skilled Nursing & Rehabilitation Center | 20 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.