Inspection visit

Health inspectionMay 22, 2025

WOLF CREEK CARE CENTERCMS #0555126 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with the facility's policy and procedures as well as professional standards of care for one out of 16 sampled residents (Resident 20), when Resident 20 did not receive insulin (hormone that controls the amount of sugar in the blood) medication within the parameters as ordered by the physician. Residents Affected - Few This failure had the potential for Resident 20 to experience hypoglycemia (condition where the level of sugar in the blood drops below a healthy range) and for the resident to not achieve their highest practicable well-being. Findings: Resident 20 was originally admitted to the facility in September 2022 with multiple diagnoses which included type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin). A review of Resident 20's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated, Resident 20 was cognitively intact. During a review of Resident 20's Order Summary Report, dated 5/21/25, Resident 20 had an order for, Insulin Glargine [long-acting synthetic version of human insulin used to treat diabetes] Solution 100 UNIT/ML [unit of measure] Inject 18 unit subcutaneously [under the skin] at bedtime for DM [diabetes mellitus] Hold for FSBS [finger stick blood sugar- test that measures the level of sugar in a small drop of blood] less than 150, with a start date of 7/15/24. During a concurrent interview and record review on 5/20/25, at 2:48 p.m., with Licensed Nurse 1 (LN 1), Resident 20's Medication Administration Record (MAR, a legal document used to record medications given to the residents) for the month of May 2025 was reviewed. LN 1 confirmed Resident 20 had FSBS less than 150 on 5/2/25, 5/6/25, 5/10/25, and 5/13/25 but the MAR indicated insulin was given. LN 1 stated insulin should not have been given on those days because the order stated to hold insulin if FSBS was less than 150. LN 1 stated the expectation were for nurses to always follow the physician orders. LN 1 further stated that not following the physician orders could have potentially been dangerous for Resident 20 and result in them experiencing hypoglycemia. During an interview on 5/21/25, at 9:33 a.m., with the Director of Nursing (DON), DON stated it was the expectation of nursing staff to always follow physician orders including parameters when administrating medications. The DON confirmed that not following physician orders could potentially cause harm to the resident and result in a change of condition. A review of Resident 20's care plan initiated on 10/3/22, indicated, .Fluctuating blood sugars. At (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 055512 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few risk for ill effects such as: Hypoglycemia (Tremors, Confusion, and Diaphoresis [sweating]) .Medication as ordered . During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration, revised 10/24, the P&P indicated, .The type of insulin, dosage requirements .are verified before administration to assure that it corresponds with the physician's order. During a review of the facility's P&P titled, Physician Orders, dated 10/24, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order. During a review of the facility's P&P titled, Administering Medications, revised 10/24, the P&P indicated, Medications are administered in accordance with prescribers' orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, the facility failed to ensure one out of 16 sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 2's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) drainage bag was not positioned below Resident 2's bladder during a wound care treatment. This failure had the potential for Resident 2 to develop infection and possible suprapubic catheter complications. Findings: A review of Resident 2's clinical record indicated Resident 2 was initially admitted September of 2024 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body), urinary tract infection (UTI- an infection in the bladder/urinary tract), and obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing properly causing backflow of urine from the bladder into the ureters). A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/9/25, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 2 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 2's MDS Bladder and Bowel conditions, dated 4/9/25, indicated Resident 2 has Indwelling catheter [a flexible tube inserted into the bladder and left in place to drain urine] (including suprapubic catheter .) A review of Resident 2's care plan, dated 4/8/25, indicated, [Resident 2] has a Suprapubic Catheter r/t [related to] OBSTRUCTIVE AND REFLUX UROPATHY. A review of Resident 2's care plan intervention, dated 4/8/24, indicated, CATHETER: .suprapubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. During a concurrent observation and interview on 5/19/25 at 12:36 p.m. with Resident 2, in Resident 2's room, Resident 2 was observed connected to a urinary catheter tubing and bag draining yellowish liquid. The urinary bag was covered with privacy bag and hung on Resident 2's bedside. Resident 2 stated she recently got hospitalized because of UTI. During an observation on 5/20/25 at 10:04 a.m. with the Treatment Nurse (TN), in Resident 2's room, the TN was observed doing Resident 2's wound care treatment on Resident 2's back. The TN placed Resident 2's bed in a flat position, turned Resident 2 sideways, and placed Resident 2's suprapubic catheter drainage bag on the bed, next to her legs. Resident 2's drainage bag was not kept below Resident 2's bladder all throughout the wound care treatment. During a subsequent interview on 5/20/25 at 10:19 a.m. with the TN, in Resident 2's room, the TN confirmed that Resident 2's suprapubic catheter drainage bag was placed on Resident 2's bed and was not kept below Resident 2's bladder all throughout the wound care treatment. The TN stated the drainage bag should be always placed below Resident 2's bladder to prevent back flow of the urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/21/25 at 9:44 p.m. with the Infection Preventionist (IP), the IP stated that urinary catheter bag should have been placed below the resident's bladder because there would be a risk for the urine to flow back into the bladder causing possible UTI or other catheter complications. During an interview on 5/21/25 at 11:28 p.m. with the Director of Nursing (DON), the DON stated that the urinary catheter bag should always be placed below the resident's bladder. The DON further stated there would be a risk of infection or other complications if the catheter bag is not placed below the resident's bladder. A review of the facility's policies and procedures titled, Indwelling Catheters, revised 9/2021, indicated, Maintaining Unobstructed Urine Flow .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one out of 16 sampled residents (Resident 43) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 43's pain medication orders were not consistently followed. Residents Affected - Few This failure had the potential for Resident 43 to experience over medication, not achieve pain relief, and not attain her highest practicable well-being. Findings: A review of Resident 43's clinical record indicated Resident 43 was admitted April of 2025 and had diagnoses that included infection following a surgical procedure, fracture (a break in the continuity of a bone) of left lower leg, osteomyelitis (a serious infection of the bone), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), and opioid dependence (reliance on a substance found in certain prescription pain medications). A review of Resident 43's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/2/25, indicated Resident 43 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 43 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 43's MDS Health Conditions, dated 5/2/24, indicated Resident 43 occasionally experiences pain and received routine and as needed pain medications, and non-medication intervention for pain. A review of Resident 43's care plan, revised 5/1/25, indicated, Pain: [Resident 43] is at risk for acute pain or discomfort due to wounds, decreased mobility, Neuropathy. A review of Resident 43's care plan intervention, initiated 4/30/25, indicated, Administer medications as ordered . A review of Resident 43's physician's order, dated 4/30/25, indicated, Ibuprofen [a medication for pain] Oral Tablet 200 MG [milligrams- unit of measurement] .Give 2 tablet by mouth every 6 hours as needed for Mild Pain (1-3) [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain]. A review of Resident 43's physician's order, dated 4/30/25, indicated, oxyCODONE HCl [a controlled medication used to treat moderate to severe pain] Oral Tablet 10 MG .Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe pain (7-10) for 7 Days. A review of Resident 43's physician's order, dated 5/13/25, indicated, oxyCODONE HCl Oral Tablet 10 MG .Give 1 tablet by mouth every 12 hours as needed for Moderate to Severe pain (7-10). During an interview on 5/19/25 at 9:40 a.m. with Resident 43, Resident 43 stated she was not getting her pain medications on time which causes her to experience severe pain at times. A review of Resident 43's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of May 2025 indicated Resident 43 received ibuprofen which was as needed for mild pain on the following occasions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 5/8/25 at 2:23 p.m.- pain level was 5 (moderate pain) Level of Harm - Minimal harm or potential for actual harm 5/9/25 at 12:49 p.m.- pain level was 5 (moderate pain) 5/15/25 at 10:42 a.m.- pain level was 5 (moderate pain) Residents Affected - Few 5/16/25 at 2:14 p.m.- pain level was 7 (severe pain) 5/17/25 at 11:49 a.m.- pain level was 5 (moderate pain) 5/19/25 at 11:58 a.m.- pain level was 10 (severe pain) 5/20/25 at 2:39 p.m.- pain level was 6 (moderate pain) A review of Resident 43's MAR for the month of May 2025 indicated Resident 43 received oxycodone which was as needed for moderate to severe pain on the following occasions: 5/6/25 at 6:15 a.m.- pain level was 0 (no pain) 5/8/25 at 4:31 a.m.- pain level was 3 (mild pain) 5/14/25 at 5:06 a.m.- pain level was 0 (no pain) 5/19/25 at 7:20 a.m.- pain level was 0 (no pain) 5/21/25 at 4:37 a.m.- pain level was 0 (no pain) During a concurrent interview and record review on 5/21/25 at 9:33 a.m. with Licensed Nurse (LN) 2, Resident 43's clinical records were reviewed. LN 2 confirmed that Resident 43's pain medication orders were not consistently followed. LN 2 stated the resident would either have an unrelieved pain or experience overmedication complications if the physician's order is not followed. LN 2 further stated that nurses should always follow the physician's order when administering pain medication. During an interview on 5/21/25 at 11:28 a.m. with the Director of Nursing (DON), the DON stated she would expect staff to assess the resident's pain level first and the pain level should accurately reflect the needed pain medication. The DON further stated the resident's pain would not be managed well or the resident would be overmedicated if the physician's order was not followed. A review of the facility's P&P titled, Pain Assessment and Management, revised 9/2024, indicated, Implementing Pain Management Strategies .3. Implement the medication regimen per Physician orders. A review of the facility's P&P titled, Administering Medications, revised 10/2024, indicated, 2. Medications are administered in accordance with prescriber orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for a census of 53 residents when the Registered Dietician (RD) and Dietetic Services Supervisor (DSS) were both hired as part time (an employee who is scheduled to work and who does work a schedule of anything under 32 hours per week) employees. This failure had the potential for unsafe food handling and spread of food borne illnesses in a highly susceptible population. Findings: During an interview on 5/19/25 at 9:40 a.m. with the DSS, the DSS stated she was working as a part time employee for the facility and was also working at another facility. The DSS further stated that their RD was also working as part time employee and the Dietetic Services Supervisor in Training (DSSIT) who was not yet licensed, was working as full-time employee. A review of the DSS's employment document titled, New Hire Input Form, dated 9/7/24, indicated the DSS was hired as a part time employee of the facility on 9/7/24. During an interview on 5/20/25 at 10:52 a.m. with the DSSIT, the DSSIT stated she was working as a full-time employee for the facility. The DDSIT further stated she was currently doing online schooling and will take the Certified Dietary Manager (CDM) examination within four months. A review of the DSSIT's employment document titled, New Hire Input Form, dated 1/27/25, indicated the DSSIT was hired as a full-time employee of the facility on 1/27/25. During an interview on 5/21/25 at 10:01 a.m. with the RD, the RD stated she was working as a part time employee for the facility. A review of the RD's employment document titled, New Hire Input Form, dated 9/11/23, indicated the RD was hired as a part time employee of the facility on 9/11/23. During an interview on 5/21/25 at 11:08 a.m. with the administrator (ADM), the ADM stated that state regulations should be followed. A review of the facility's policies and procedures titled, PERSONNEL MANAGEMENT, undated, indicated, A qualified FNS [Food and Nutrition Services] Director is responsible for the total operation of the Food & Nutrition Services Department. All food & Nutrition service is performed under their direction. PROCEDURE: If a person is not a Registered Dietician, they must meet the Federal and State laws . A review of the California Health and Safety Code, section 1265.4, current as of dated 1/1/23, indicated, (a) A licensed health facility .shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations .(b) The dietetic services supervisor shall have completed at least one of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm following educational requirements: .(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association . (https://codes.findlaw.com/ca/health-and-safety-code/hsc-sect-1265-4/) Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure food storage and preparation, and maintenance of food contact surfaces were in accordance with professional standards for food safety for the 53 residents who ate facility prepared meals when: 1. Three out of three small cutting boards had stains, and two out of six large cutting boards had deep scratches; and, 2. A box of garlic bread, a box of fried eggs, and a box of bacon were found with ice crystals built-up, opened and were exposed to air in the freezer. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 5/19/25, within the initial kitchen tour beginning at 8:23 a.m., with the Dietetic Services Supervisor in Training (DSSIT), three out of three small cutting boards were found stained with brownish substance, and two out of six large cutting boards were found with deep scratches. The DSSIT confirmed the observation and stated cutting boards with stains and deep scratches could potentially harbor bacteria. During an interview on 5/21/25, at 10:01 a.m., with the Registered Dietician (RD), the DM stated bacteria might get into those uncleaned cutting board stains or in the groves of those cutting board scratches. The RD further stated cutting boards with stains and deep scratches are risk for bacterial overgrowth and possible foodborne illnesses. A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 4-501.12, titled Cutting Surfaces, 1/18/23 version, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 2. During a concurrent observation on 5/19/25, within the initial kitchen tour beginning at 8:23 a.m., with the DSSIT, a box of garlic bread, a box of fried eggs, and a box of bacon were all found with ice crystals built-up, opened, and were exposed to air in the freezer. The DSSIT confirmed the observation. During an interview on 5/21/25, at 10:01 a.m., with the RD, the RD stated food items should be tightly sealed when placed in the freezer. The RD further stated the texture and taste of the food could get affected because of the ice crystals build-up. A review of facility's policies and procedures titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, indicated, 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn (a condition in which ice crystals form on frozen food as the result of air coming into contact with food). A review of the US FDA 2022 Food Code, section 3-302.11, titled Packaged and Unpackaged Food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm -Separation, Packaging, and Segregation, 1/18/23 version, indicated, (A) FOOD shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings . A review of the US FDA article titled, Are You Storing Food Safely?, dated 1/18/23, indicated, .Freezer burn is a food-quality issue . (https://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely) Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of 16 sampled residents (Resident 17) when: Residents Affected - Some 1. Resident 17's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days and was left uncovered when not in use; and, 2. Resident 17's oxygen nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not changed every seven days. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure to germs, and may cause infection to Resident 17. Findings: 1. A review of Resident 17's clinical record indicated Resident 17 was admitted April of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), and shortness of breath A review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/30/25, indicated Resident 17 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 17 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 17's MDS Health Conditions, dated 4/30/24, indicated Resident 17 experienced shortness of breath or trouble breathing when lying flat. A review of Resident 17's physician's order, dated 4/28/25, indicated, Budesonide [a medication that reduces inflammation and swelling] Suspension [a mixture where solid particles are mixed with but not dissolved in a liquid] 0.5 MG [milligram- unit of measurement] /2ML [milliliters- unit of measurement] 2 ml inhale orally via nebulizer two times a day for COPD exacerbation [worsening]. During a concurrent observation and interview on 5/19/25 at 9:34 a.m. with Resident 17, in Resident 17's room, Resident 17's nebulizer face mask and tubing was labeled 5/6 and was placed on top of Resident 17's bedside drawer, uncovered. Resident 17 stated she last used her nebulizer last night. During a concurrent observation and interview on 5/19/25 at 10:15 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 17's room, CNA 1 confirmed that Resident 17's nebulizer face mask and tubing was labeled 5/6 which was 2 weeks ago and was placed on top of Resident 17's bedside drawer, uncovered. CNA 1 stated that nebulizer face mask and tubing should be changed every Sunday and should be placed in a black bag when it is not being used for infection control. 2. A review of Resident 17's physician's order, dated 4/29/25, indicated, Oxygen - @ 2 Liters/Min [liters per minute- unit of measurement for oxygen administration flow rate] Via Nasal Cannula (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Continuous Medical DX [diagnosis]: COPD . Level of Harm - Minimal harm or potential for actual harm A review of Resident 17's physician's order, dated 4/29/25, indicated, Change Nasal Cannula. every night shift every Sun [Sunday] AND as needed. Residents Affected - Some During a concurrent observation and interview on 5/19/25 at 9:34 a.m. with Resident 17, in Resident 17's room, Resident 17 was sitting on the side of her bed, awake, and was on oxygen set at 2 LPM via nasal cannula which was labeled 5/11. Resident 3 stated she uses oxygen all the time. During a concurrent observation and interview on 5/19/25 at 10:15 a.m. with CNA 1, in Resident 17's room, CNA 1 confirmed that Resident 17's oxygen nasal cannula was labeled 5/11. CNA 1 stated oxygen nasal cannula should be changed every Sunday. During an interview on 5/21/25 at 9:44 a.m. with the Infection Preventionist (IP), the IP stated that nebulizer face mask and tubing should always be placed in a bag when not being used and should be changed every Sunday. The IP also stated oxygen nasal cannula should also be changed every Sunday. The IP further stated there would be a risk of infection or possible exposure of the resident to bacteria if the nebulizer face mask is left uncovered and not being changed every week, and if the oxygen nasal cannula is not being changed every week. During an interview on 5/21/25 at 11:28 a.m. with the Director of Nursing (DON), the DON stated she would expect nebulizer face mask and oxygen nasal cannula to be changed every seven days for infection control. The DON further stated she would expect the nebulizer face mask to be clean and placed inside the black bag when not being used. A review of the facility's policy and procedures (P&P) titled, Respiratory Care and Oxygen Administration, revised 10/2024, indicated, Oxygen therapy is administered by way of .nasal cannula .c. The oxygen tubing is changed at least weekly, labeled with the date it was changed .Infection Control Considerations Related to Medication Nebulizers/Continuous .5. Store the nebulizer mask in the antimicrobial bag, marked with date and resident's first initial and last name. 6. Discard the nebulizer tubing and mask at least weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055512 If continuation sheet Page 12 of 12

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0801GeneralS&S Fpotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the May 22, 2025 survey of WOLF CREEK CARE CENTER?

This was a inspection survey of WOLF CREEK CARE CENTER on May 22, 2025. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WOLF CREEK CARE CENTER on May 22, 2025?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 22, 2025