Health inspection·March 18, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and facility policy review, the facility failed to implement their Abuse policy and investigate an injury of unknown origin for one of three residents who were sampled for abuse (Resident 1), when Resident 1 was found to have a bruise on her left hip and the facility could not determine where the bruise came from, in order to rule out abuse. Residents Affected - Few This failure had the potential for residents not to be protected against abuse in the facility, which could negatively impact their quality of life and physical, emotional and psychosocial well-being. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property; Prevention Of reviewed 4/17/24, indicated, D. Complaints, observations, suspicions, or reporting of incidents, falls, bruises and skin tears (of suspicious or unknown origin) will be investigated to rule out abuse. Occurrences, patterns, and trends will be assessed by administrative staff, licensed staff, and the interdisciplinary team to determine the corrective action based on the results of the investigation. Results will be reported to the Administrator .for further directions and action plans. F. All incidents of suspected or alleged abuse will be investigated by the assigned staff. The assigned staff will be informed of the nature of the incident and continue the investigation process. The investigation and report shall include: a) Date and time the incident took place. b) Circumstances surrounding the incident. c) Where the incident occurred. d) Names of witnesses and their account when applicable. e) Resident's/representative's account of incident. f) Employee's account of incident when applicable. g) Accounts of any other individuals involved. h) Recommendations for corrective action if applicable. i) Outcome of investigation; and j) Follow-up resolution or further action if necessary. 2. Suspicious falls and other incidents of unknown origin will be investigated to rule out abuse. During a record review of Resident 1's admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included frontotemporal neurocognitive disorder (group of brain disorders), tremors (involuntary, rhythmic shaking movements), and dementia (a decline in mental ability). A review of Resident 1's most recent Minimum Data Set (MDS, a standardized assessment tool), indicated that Resident 1 had memory, recall and decision making problems. During a review of Resident 1's clinical record, there was only one document that indicated that the facility had found a bruise on Resident 1. A Progress Notes Communication with Physician dated 3/14/25 at 3:14 pm, reflected that a nurse had reached out to Resident 1's Hospice provider (supports (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 6 Event ID: 056391 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 056391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Empire 121 Dorsey Drive 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)