Health inspection·July 30, 2025

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Resident 1's rights were protected when:1. Licensed Nurse (LN) B administered a PPD test (purified protein derivative, injected under the skin to determine if a person had tuberculosis, a contagious bacterium that had the potential to cause death) after Resident 1's responsible party (RP, decision maker) had declined administration of the PPD test. 2. The facility provided medication to Resident 1 based on the RP's decisions rather than assessment data and concerns regarding Resident 1's appearance of being sedated. These failures violated Resident 1's rights. Findings: 1. A review of the Resident [NAME] of Rights, dated 12/1/12, indicated, residents had the right to refuse any treatment or procedure. A review of the facility's policies and procedures (P&P) titled, Requesting, Refusing, and/or Discontinuing Care or Treatment, revised 2/1/21, indicated, the resident and or the residents RP had the right to refuse treatment. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own RP. A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses of pressure ulcer of sacral region, unstageable (a painful wound that was caused by pressure, located at the tail bone area. The wound was unstageable because dead tissue covered the wound making wound depth measurements and visual inspection impossible), depression (a sad mood), and dementia (memory loss). During an interview on 7/24/25 at 10:10 am, Resident 1's RP stated, on August 11th Resident 1 was given a TB shot [PPD test] without my permission. During a concurrent interview and record review on 7/29/25, at 2:10 pm, with LN B, Resident 1's Medication Administration Record (MAR), dated 8/11/24 was reviewed. LN B confirmed, the MAR indicated, LN B performed a PPD skin test on Resident 1 and stated, when he [RP] came back to the room, I alerted him I gave the PPD, I did not know it was refused previously, and the order to give the PPD was still in the computer. LN B reviewed the MAR, dated 8/5/24, and confirmed the MAR indicated the PPD had been refused. LN B stated, my view of the MAR was not of the entire month, it only showed what was due that day, so I couldn't see that it had been refused. During an interview on 7/29/25 at 10:15 am, Director of Nursing (DON) confirmed, Resident 1 had been provided the PPD skin test on 8/11/24 and stated, the nurse didn't remove the PPD order from the system and that's why LN B provided the PPD. After it was originally refused, the nurse should have removed the order and entered a note. 2. A review of the Resident [NAME] of Rights, dated 12/1/12, indicated, residents had the right to be free from excessive medication. A review of the Medication Review Report, dated 7/30/25, indicated, Resident 1 received Buspirone HCL (Buspar, a medication that was used to treat anxiety) 15 milligrams (mg, unit of measure), give 1 tablet by mouth three times a day for anxiety manifested by continuous calling out after needs have been met. The Medication Review Report, indicated, Resident 1 received oxycodone HCL (a strong opioid pain medication that had the potential to cause sedation and drowsiness. When using oxycodone and Buspirone together, potential risks and side effects included an Residents Affected - Few Page 1 of 8 055640 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few increased risk of profound sedation [depressed consciousness], drowsiness, and impaired judgement) 10mg, give one tablet by mouth three times a day for pain and may also give every 4 hours as needed for pain that was scored 4-10 out of 10 on the pain scale. During an interview on 7/24/25 at 10:10 am, Resident 1's RP stated, I'm concerned about her [Resident 1's] anxiety, they started her on a lower level once a day, then they increased to twice a day, then we moved it to three times a day. I just told them, it's helped a lot, there are still minor break outs [related to Resident 1's yelling out], so I asked to up the dosage. During an interview on 7/30/25 at 8:44 am, facility's physician (MD) stated, Resident 1's RP is concerned about the pain, he was pushing for stronger pain medications, we accommodated his request and her pain control really isn't bad. During an interview on 7/30/25 at 9:18 am, LN G stated, Resident 1's RP would by-pass the nurse and go to the DON to complain Resident 1 was in pain and demand more pain meds. I went once to assess Resident 1's pain after the RP said she was in pain, and the RP said, say your pain is a 7, then Resident 1 agreed her pain was a 7. LN G stated, prior to RPs arrival Resident 1 stated she had no pain. LN G stated, sometimes the PRN (as needed dose of oxycodone) was held because nurses felt uncomfortable giving it because she appeared to be sedated or sleepy and the RP would demand that pain meds still be given. LN G stated, there were times when Resident 1 was provided PRN pain medication [oxycodone] due to the RP pushing pain meds and convincing Resident 1 she was in pain, so it's given. During a review of the IDT (Interdisciplinary Team, a group of facility staff such as department heads and staff that provided direct resident care, met to discuss resident care concerns and goals) Note, dated 5/21/25, indicated, PHARM F was notified Resident 1's RP had concerns about Resident 1's medication and RP felt sometimes Resident 1 was sedated. The ID note indicated that the doctor had ordered a decrease in Resident 1's pain medication and the RP did not want the pain medication changed. The IDT note indicated that the RP did not feel Resident 1 was sedated and was more concerned about addressing Resident 1's calling out. During an interview on 7/30/25 at 11:06 am, Pharmacist (PHARM) F, stated, one time while I was at the facility, I was told the RP didn't care about sedation anymore and just wanted to keep Resident 1 comfortable. During a review of the Care Plan Conference Notes, dated 5/29/25, indicated, Resident 1's RP was in attendance and Concerns-increased sedation/groggy were discussed. The Care Plan Conference Notes, indicated, Resident 1's Buspar would be increased to 15 mg today and MD suggest decrease of Oxycodone dose, declined at that time by RP. 055640 Page 2 of 8 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their pain management policies and procedures (P&P) for three out of three residents (Residents 1, 2, and 3) when: 1. Resident 1 had high PRN (as needed and must be asked for) pain medication usage for eight months prior to evaluating the need to change the current pain medication regimen. 2.The facility failed to determine if Resident 1's behavior of screaming was caused by pain, anxiety, or related to a diagnosis of dementia. 3a. Non-pharmacological interventions (any health intervention that was used to assist with managing chronic pain and did not involve the use of medication. Examples included but were not limited to distraction, music, re-positioning, stretching, or activities) were not implemented or monitored for effectiveness for Resident 1. 3b. Non-pharmacological interventions were not implemented or monitored for effectiveness for Resident 2. 3c. Non-pharmacological interventions were not implemented or monitored for effectiveness for Resident 3. These failures had the potential to cause resident harm, inconsistent pain control, a decline in health status, and to negatively impact the residents' overall well-being. Findings: 1. A review of the facility's P&P titled, Pain Assessment and Management, revised 10/1/22, indicated, The purposes of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated, the facility would review how often the individual requested and received PRN pain medication and would consider administering regularly scheduled pain medication rather than PRN. The P&P indicated, the facility would monitor the resident to ensure the pain was being adequately controlled. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own responsible party (RP, decision maker). A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses of pressure ulcer of sacral region, unstageable (a painful wound that was caused by pressure, located at the tail bone area. The wound was unstageable because dead tissue covered the wound making wound depth measurements and visual inspection impossible), depression (a sad mood), and dementia (memory loss). A review of Resident 1's admission Minimum Data Set (MDS, a resident assessment tool), dated 8/15/24, indicated, the facility performed a Brief Interview for Mental Status assessment (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) and scored a 5 out of 15 which indicated severe cognitive (memory, orientation, judgement) impairment. The MDS indicated Resident 1 had received scheduled and PRN pain medication and occasionally had pain. A review of Resident 1's care plan (a document that described resident healthcare needs, goals, and interventions [actions taken by facility staff] required to achieve those goals) titled Pain, dated 8/6/24, indicated, the facility staff would monitor the resident for requests for pain treatment and review pain medication dosing schedules for resident satisfaction. A review of the Order Details, dated 8/5/24, indicated the Physician ordered Gabapentin (an anticonvulsant medication that was used to treat seizure disorders and treated nerve pain) 400 milligrams (mg, a unit of measure) by mouth three times a day for pain that was caused by Resident 1's pressure ulcer. A review of the Order Details, dated 8/5/24, indicated the Physician ordered Oxycodone (a strong narcotic that was used to treat moderate to severe pain) 10 mg by mouth every four hours as needed (PRN) for moderate to severe pain (pain was rated on a scale of 0 through 10 out of ten, 0 meant no pain and 10 meant the worst pain, moderate to severe pain was rated as a 4 through 10). During an interview on 7/29/25 at 3:05 pm, Director of Nursing (DON) stated, the amount the PRN [pain medication] was provided [to Resident 1] was the same as if it had been given on a routine Residents Affected - Some 055640 Page 3 of 8 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some basis. A review of Resident 1's Medication Administration Record (MAR), dated 8/5/24 through 8/31/24, indicated that a request for PRN Oxycodone was made 62 times. A review of Resident 1's MAR, dated 9/1/24 through 9/30/24, indicated that a request for PRN Oxycodone was made 85 times. A review of Resident 1's MAR, dated 10/1/24 through 10/31/24, indicated that a request for PRN Oxycodone was made 73 times. A review of Resident 1's MAR, dated 11/1/24 through 11/30/24, indicated that a request for PRN Oxycodone was made 71 times. A review of Resident 1's MAR, dated 12/1/24 through 12/31/24, indicated that a request for PRN Oxycodone was made 77 times. A review of Resident 1's MAR, dated 1/1/25 through 1/31/25, indicated that a request for PRN Oxycodone was made 73 times. A review of Resident 1's MAR, dated 2/1/25 through 2/28/25, indicated that a request for PRN Oxycodone was made 62 times. A review of Resident 1's MAR, dated 3/1/25 through 3/21/25, indicated that a request for PRN Oxycodone was made 49 times. From 8/5/24 through 3/21/25, Resident 1 or her RP was required to ask for pain medication 552 times before the pain medication regimen was re-evaluated and changed. During an interview on 7/30/25 at 8:44 am, the facility's Physician (MD) stated, Resident 1's pain control isn't really bad, we previously discussed pain medications and accommodated the request made by the RP. A review of Resident 1's Order Details, dated 3/21/25, indicated, MD changed the PRN Oxycodone order to include the addition of Oxycodone 10 mg one tablet by mouth three times a day for pain. During an interview on 7/30/25, at 9:34 am, Pharmacist (PHARM) E stated, when we see high usage of PRN pain medication, there is some recommendation to give an extended release [a longer acting medication that controlled pain for a longer period]. PHARM E confirmed, when there was a high PRN pain medication usage, the pharmacist will recommend the pain medication regimen to be re-evaluated. PHARM E stated, the best person to talk to [regarding Resident 1] was PHARM F. During a concurrent interview and record review on 7/30/25 at 11:06 am, PHARM F stated, high usage of PRN pain medication was hard to answer because it is different for each resident. PHARM F reviewed the MAR dated 9/1/24 through 9/30/24 and confirmed more than half of the PRN pain medication that was administered to Resident 1, indicated she had pain that was scored at a 7 or 8 out of 10 (pain that was rated 7 through 10 was considered severe pain). PHARM F stated, I sent a letter to the doctor in January, a documented progress note, indicating high PRN med use. Pharm F was asked if there was a time frame regarding high PRN medication use and notifying the doctor and no time frame was provided. A review of Resident 1's progress note titled, Pharmacy Consultant Note, dated 1/30/25 (five months after Resident 1's admission to the facility), indicated, Resident takes PRN oxycodone often. The progress note did not indicate that the Physician had been notified. 2. A review of the facility's P&P titled, Pain Assessment and Management, revised 10/1/22, indicated, the facility would be able to recognize non-verbal signs of pain to include screaming. The P&P indicated, facility staff would consider cognitive .influences [for example, a diagnosis of dementia] on the president's ability or willingness to verbalize pain are considered when assessing and treating pain. During an interview on 7/29/25 at 2:10 pm, LN B stated, she [Resident 1] yells all the time, not always due to pain, it could be anxiety or just behaviors, unsure which. During an interview on 7/30/25 at 11:06 am, PHARM F stated, so many medications were added and changed to determine if she [Resident 1] had pain or if it was just screaming. PHARM F confirmed, it was unknown if Resident 1 was screaming due to pain, anxiety, or dementia related behaviors. During a concurrent interview and record review on 7/30/25 at 2:37 pm, medical records were requested that indicated the facility had determined the root cause of Resident 1's yelling and screaming was related to pain or a different condition. DON provided psychotropic (medications that affected how the brain worked) notes, dated 12/16/24, 12/18/24, 3/24/25, 4/15/25, 4/30/25, 5/22/25, and 7/28/25. DON confirmed there was no documentation present, including the psychotropic notes that 055640 Page 4 of 8 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated the facility had discussed or determined if Resident 1 was yelling due to pain, anxiety, or dementia related behaviors. 3a. A review of the facility's P&P titled, Pain Assessment and Management, revised 10/1/22, indicated, Non-pharmacological interventions may be appropriate alone or in conjunction with medications. The P&P indicated some examples of non-pharmacological interventions included but were not limited to, adjusting the room temperature, repositioning, ice packs, exercise, relaxation, music, diversions, and activities. The P&P indicated, the facility would monitor and evaluate the effectiveness of interventions in place. A review of the RAI (Resident Assessment Instrument, a set of instructions that assisted facility staff to accurately code the MDS) instructions for pain management, dated 10/1/24, indicated, Non-medication pain (non-pharmacologic) interventions for pain can be important adjuncts to pain treatment regimens. The RAI indicated, interventions included, but were not limited to use of heat and or cold therapy, exercise, and ultra-sound (use of sound waves to treat pain). A review of Resident 1's MDS, dated [DATE], indicated, Resident 1 occasionally had moderate (significant but not severe) pain and did not receive non-pharmacological pain interventions. A review of Resident 1's care plan titled, Pain, dated 8/6/24 indicated, Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Resident 1's Medication Review Report, dated 7/30/25, that included all active and current orders, did not include an order to provide Resident 1 with non-pharmacological interventions or to monitor for effectiveness. During an interview on 7/30/25 at 9:18 am, LN G stated, there isn't anywhere to chart daily non-pharmacological interventions, it's documented in the weekly assessments. A review of Resident 1's Weekly Nursing Summary V.5, dated 1/8/25, indicated, Resident 1 did not receive non-pharmacological pain interventions that week. There was no place to document what non-pharmacological interventions had been provided, if any. A review of Resident 1's Pain Assessment Records, dated 8/12/24, indicated, the facility's occupational therapist (healthcare professional that helped residents to perform tasks that were required for independent living) was working with Resident 1 with positioning in wheelchair for comfort. The Pain Assessment Records, dated 11/5/24, 2/7/25, 3/6/25, and 6/27/25, indicated, nonpharmacological interventions had not been provided for pain and the section that required documentation describing interventions and effectiveness was blank. 3b. A review of Resident 2's Medical Diagnosis, dated 12/6/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of radiculopathy, lumbar region (nerve pain, caused by a pinched nerve, in the lower back) and age related osteoporosis without current pathological fracture (weak, brittle bones that were caused by aging and did not include any broken bones). A review of Resident 2's quarterly MDS, dated [DATE], indicated, Resident 2 occasionally had moderate (significant but not severe) pain and did not receive non-pharmacological pain interventions. A review of Resident 2's care plan titled, Pain, dated 12/6/24, indicated, Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Resident 2's Medication Review Report, dated 7/30/25, that included all active and current orders, did not include an order to provide Resident 1 with non-pharmacological interventions or to monitor for effectiveness. A review of Resident 2's Pain Assessment Records, dated 12/9/24, 3/9/25, and 6/13/25, indicated, non-pharmacological interventions had not been provided for pain and the section that required documentation describing interventions and effectiveness was blank. 3c. A review of the Clinical Resident Profile, dated 6/24/24, indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's Medical Diagnosis, 055640 Page 5 of 8 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 6/24/24, indicated Resident 3 was admitted to the facility with the diagnosis of acquired absence of right and left leg above the knee (both legs were surgically removed just above the knee, sometimes people felt pain where their leg used to be). A review of Resident 3's annual MDS, dated [DATE], Resident 3 occasionally had moderate (significant but not severe) pain and did not receive non-pharmacological pain interventions. A review of Resident 3's care plan titled, Pain, dated 6/25/24 indicated, Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Resident 3's Medication Review Report, dated 7/30/25, that included all active and current orders, did not include an order to provide Resident 1 with non-pharmacological interventions or to monitor for effectiveness. A review of Resident 3's Pain Assessment Records, dated 6/28/24 and 6/26/25 indicated, non-pharmacological interventions had not been provided for pain and the section that required documentation describing interventions and effectiveness was blank. During an interview on 7/30/25 at 2:37 pm, DON confirmed, non-pharmacological interventions had not been provided or documented for effectiveness for residents in the facility that experienced pain. 055640 Page 6 of 8 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policies and procedures (P&P) regarding medication administration documentation for one out of three sampled residents (Resident 1) when Licensed Nurse (LN) B initialed the medication administration record (MAR) for a medication that LN A prepared and administered to Resident 1. This caused inaccurate documentation and had the potential to negatively impact resident safety.Findings: A review of the facility's P&P titled, Administering Medications, revised 4/1/19, indicated, The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next dose. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own responsible party (RP, decision maker). A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses of pressure ulcer of sacral region, unstageable (a wound that was caused by pressure, located at the tail bone area. The wound was unstageable because dead tissue covered the wound making wound depth measurements and visual inspection impossible), depression (a sad mood), and dementia (memory loss). During a concurrent interview and record review on 7/29/25 at 2:10 pm, with LN B, Resident 1's MAR, dated 3/20/25 was reviewed. LN B confirmed, the MAR indicated, LN B had administered oxycodone (a strong pain killer) 10 milligrams (unit of measure), one tablet, by mouth, on 3/20/25, at 6:32 pm, to Resident 1. LN B stated, I checked off the oxycodone [in the MAR], but I didn't give it, LN A did. LN B stated, it is not normal for me to sign off a medication that I did not administer. During an interview on 7/29/25 at 3:05 pm, Director of Nurses (DON) stated, nurses should not sign out medication they did not administer. 055640 Page 7 of 8 055640 07/30/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control practices when facility staff disinfected the Hoyer lift (mechanical device used to safely transfer residents from one place to another) in the hallway, did not wear gloves, or perform hand hygiene (washing hands or using alcohol-based hand sanitizer) afterwards. This failure had the potential to spread infections to other residents, facility staff, and visitors.Findings: A review of the facility's policies and procedures, (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/1/22, indicated, facility staff would clean and disinfect medical equipment in-between resident use. A review of the facility's P&P titled, Personal Protective Equipment (PPE, items worn to prevent the spread of infection such as gowns or gloves), revised 10/1/18, indicated, PPE requirements were specific to job requirements and facility staff would wear the appropriate PPE for specific tasks. A review of the facility's P&P titled, Infection Prevention and Control, revised 12/1/23, indicated, the facility utilized infection control practices to maintain a safe environment. A review of the CaviWipes Safety Data Sheet, dated 6/29/22, indicated, facility staff were required to wear gloves while using CaviWipes (a brand name, cleansing and disinfecting wipes that were used to clean resident care equipment). The safety data sheet indicated repeated exposure could cause dry, cracked skin (this had the potential for bacteria to enter through cracked skin and cause the spread of infection). During an observation on 7/25/25 at 12:54 pm, Certified Nurse Assistant (CNA) C and CNA D were observed wiping down the Hoyer lift without wearing gloves, in the hallway, outside of room [ROOM NUMBER]. When CNA C and CNA D finished, they walked immediately into room [ROOM NUMBER] with the Hoyer lift and were not observed performing hand hygiene. During a concurrent interview and record review on 7/25/25 at 1:00 pm, with CNA C and CNA D, the entirety of the observation made was described. CNA C and CNA D confirmed the observation. CNA C stated, we should wear gloves and acknowledged not performing hand hygiene after cleaning the Hoyer lift and before entering room [ROOM NUMBER]. CNA D produced a plastic container that had a black lid with the name of CaviWipes on the label. CNA D reviewed the instructions on the label and confirmed, the label indicated gloves were to be worn while using the product. During an interview on 7/25/25 at 1:44 pm, the facility's infection preventionist (IP) confirmed the observation made of CNA C and CNA D wiping down the Hoyer lift and stated, they should be cleaning [the Hoyer lift] in the room, not in the hall, and wearing gloves. IP confirmed, hand hygiene should have been performed after wiping down the Hoyer lift. Residents Affected - Few 055640 Page 8 of 8