Grass Valley Healthcare Center
GRASS VALLEY HEALTHCARE CENTER in GRASS VALLEY, CA — inspection on September 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review, the facility failed to ensure dental services were provided in accordance with professional standards of care for one out of 24 sampled residents (Resident 7), when facility staff did not assist Resident 7 in obtaining a dental appointment as physician ordered.
This failure had the potential for Resident 7 to experience unnecessary pain and an increased risk for infection. Resident 7 was originally admitted to the facility in August 2024 with multiple diagnosis which included bacteremia (bacteria in the blood), depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities) and anemia (low levels of healthy red blood cells). A review of Resident 7's Minimum Data Set (MDS, an assessment tool) signed 6/27/25, indicated, Resident 7 had severe cognitive impairment. A review of Resident 7's Order Summary Report, with start date 7/30/25, indicated, Dental referral for dental pain.During a concurrent interview and record review on 9/24/25, at 3:21 p.m., with the Social Services Director (SSD), Resident 7's Order Summary Report was reviewed.
The SSD confirmed she was responsible for ensuring all residents with dental referrals are seen by the dentist. SSD stated all dental referrals for dental pain are scheduled immediately and residents are usually seen the next day.
The SSD confirmed Resident 7 had a physician order for a dental referral for dental pain on 7/30/25 and stated Resident 7 was not seen by the dentist after that date. SSD further stated she was not aware of the dental referral and missed scheduling it. A review of the facility's policies and procedures (P&P) titled, DENTAL CARE, undated, indicated, To assure that residents are provided with the provision of dental services.Social services shall assist the resident in obtaining access to appropriate dental services.Social service staff shall assist the resident/responsible party in scheduling dental appointments.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Grass Valley Healthcare Center
355 Joerschke Dr Grass Valley, CA 95945
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 9/23/25 at 1:22 p.m. with RD, RD confirms 1/2 portion meals should get 1/2 of the regular portion. RD stated if regular portion was three oz. of meat, 1/2 portion would equate to 1.5 oz. of meat. RD stated verbal in-services have been done regarding 1/2 portion sizes, but there have not been formal in-services and there was no policy and procedure for the staff to reference.
During a follow-up interview on 9/24/25 at 3:23 p.m. with RD, RD acknowledged the findings mentioned above during the dining observation on 9/22/25 and meal distribution observation 9/23/25. RD confirmed and stated the expectation was the dietary staff needed to follow the spreadsheet and fortified food menu.A review of facility policy and procedure (P&P) titled, JOB DESCRIPTION-Food and Nutrition Service Director, dated 2023, indicated .ability to follow prepared menus and portion control guides.DUTIES AND RESPONSIBILITIES: 1.
Schedule and supervise the FNS Staff providing in-service training. 3. Is responsible for the food preparation and service of all food and ensures approved menus and accompanying recipes are followed.
Facility ID: