Above average — CMS composite of the measures below.
The next survey window likely opens around August 2026
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 Gold Country Health Center during CMS and state inspections, most recent first.
A nurse left an unlocked computer screen unattended and accessible during med pass while stepping away to clarify an order and again when entering a resident's room. The DON stated staff were expected to lock the cart and screen to hide resident information, and the facility policy required only authorized access to EMRs and efforts to limit disclosure of PHI.
An ADON applied a lidocaine patch to a resident without dating or initialing it, an LPN began giving meds to a resident without properly identifying the resident, and the same LPN handled spironolactone without gloves even though the package labeled it hazardous. In another case, a resident had overlapping PRN pain med orders for acetaminophen and hydrocodone-acetaminophen, and the DON stated the orders should have been clarified with the physician to define when each medication was appropriate and to add pain scale parameters.
Controlled medications were not accurately documented during administration and accountability checks. An ADON gave a resident Oxycontin without first documenting removal on the CDR, and two other residents had Valium and morphine signed out of the CDR but not recorded on the MAR as administered. The DON and CP also described a controlled-substance destruction process that lacked adequate chain-of-custody safeguards and did not provide a way to detect diversion before final disposal.
Medication administration errors were observed during a med pass for two residents, resulting in a 14.81% error rate. An ADON gave Senokot instead of the ordered Senna Plus, and an LN administered carvedilol and Jardiance without food despite orders to give with a meal, while also giving only one puff of Symbicort instead of the ordered two puffs. The LN confirmed the orders and the facility policy required medications to be given in accordance with prescriber orders.
Medication labeling and storage deficiencies were identified during observation and cart audits. A resident’s inhalers were found without open dates, several OTC eye drops lacked resident-specific labeling, budesonide inhalation ampules were not kept in their foil packaging per manufacturer instructions, and another inhaler was missing an opened date. OTC medications were also observed in an unlocked, unattended supply room, and the SC, ADM, and DON confirmed the room should have been secured.
Failure to Follow Pureed Rice Recipe: A dietary staff member prepared pureed rice for three residents with dysphagia and ordered pureed diets, but added three unmeasured scoops of milk instead of following the recipe. The recipe required a measured amount of warm milk for the pureed starch, and the RD later stated it was uncertain how much milk had been added.
Expired and unlabeled food was found in dry storage and the walk-in refrigerator, including bread, pasta, hamburger rolls, and celery, and the AsstDM and DSS confirmed the items should not have been served. Surveyors also found cooked turkey roasts were still at 80 F at the two-hour point of the cool down process, and staff continued cooling instead of discarding the meat as required by the facility’s PHF cooling policy.
Improper Garbage Dumpster Disposal: A kitchen garbage dumpster was observed with two warped, gaping lids, including a 3-inch gap between the lids and the top rim. The RD stated rodents and insects had access inside the dumpster, and the PD stated he had ordered a new dumpster but had no documentation of the order with the disposal company. The facility policy stated garbage storage areas must be adequate, clean, vermin-proof, and have lids closed.
Multiple infection control failures were observed, including contaminated surfaces in the laundry clean area, a nebulizer mask left out without a bag for a resident with COPD, and a soiled dressing left in a resident’s toilet for a resident with neutropenia, a lung transplant, and immunosuppression. An LPN and another nurse were observed with long acrylic nails during med pass, one nurse disinfected a BP cuff and stethoscope without gloves, and a single-use Styrofoam tray was reused on the med cart after medication administration. Facility policies required clean linen and environmental surfaces to remain sanitary, nebulizer equipment to be stored in a plastic bag, dressings to be discarded in biohazard waste, short natural nails for direct-care staff, gloves when disinfecting equipment, and disposal of single-use items after one use.
Failure to Notify RP of COC and Appointments: Two residents, including one with dementia/Alzheimer’s disease and another with cerebral infarction and vascular dementia, had no documented RP notification regarding ENT follow-up appointments, treatment plans, or a fall-related COC with right foot injury. The ADON confirmed the records lacked documentation of RP notification, and one RP reported concern about not being informed.
A resident with a urinary catheter and moderate memory impairment was observed eating lunch in her wheelchair with the urine collection bag exposed and no privacy cover. The resident said she had never had a cover since admission and wanted one, and a CNA confirmed the bag was not covered. The IP Nurse stated catheter bags should always be covered to maintain privacy, and the facility’s dignity policy specifically includes keeping urinary catheter bags covered.
Inaccurate MDS Assessment of Pressure Ulcers: A resident admitted with pressure ulcers had a wound VAC in use and treatment orders for two stage 4 pressure ulcers, but the MDS incorrectly showed no pressure ulcers in the skin section. The MDSC confirmed the MDS was inaccurately coded based on the TAR and treatment notes, and the NC stated the assessment should have been documented accurately.
A resident admitted with a right femur fracture and vertebra fracture was not given a scheduled shower and stated she felt uncomfortable because she had not bathed since admission. The shower assignment showed morning showers were scheduled, but there was no documented shower sheet, and the DSD confirmed the resident did not refuse the shower and the assigned CNA did not provide it. The ADM stated CNAs were expected to give showers as scheduled unless refused.
Proper respiratory care was not provided for a resident with respiratory failure with hypoxia when nebulizer tubing and a nasal cannula were not changed after seven days. An LPN confirmed both items were last replaced on the label date and stated they had not been changed within the required timeframe. The DON stated staff were expected to follow the facility’s respiratory equipment policy, which required the nebulizer administration set-up to be discarded every seven days.
A resident dependent on staff for ADLs, including bathing, was not provided a scheduled shower for five days, despite being on a regular shower schedule. The resident reported feeling unclean and dissatisfied, and staff interviews confirmed the missed showers were not documented as refusals. This lapse did not align with facility policy to promote resident dignity and well-being.
The facility failed to maintain food safety standards, with a dirty microwave, improperly stored wet pans, and spoiled produce not discarded. Additionally, a dietary aide was unable to correctly verbalize the manual dishwashing procedure, posing a potential risk of food-borne illness to 59 residents.
The facility failed to maintain a clean environment due to improperly secured garbage dumpsters. All three dumpsters outside had bent and deformed lids, preventing secure closure. The Dietary Supervisor confirmed the need for new bins and acknowledged the importance of tightly closed lids to prevent pest issues. Facility policy and FDA Food Code require sealed, leak-proof containers with tight-fitting lids for food waste, which was not adhered to, posing a risk for pest infestation and disease spread.
The facility failed to follow prescribed therapeutic diets for residents, including incorrect food textures and portions for those on dysphagia mechanical, controlled carbohydrate, and finger food diets. These errors were confirmed by the Registered Dietitian and Dietary Supervisor, potentially compromising residents' medical and nutritional status.
A facility failed to maintain a homelike environment for a resident when the chain to operate the overhead light in the resident's room was broken and unreachable. This issue persisted since the resident's admission, preventing them from independently controlling the light. Both a nurse and the DON acknowledged the problem, confirming the chain was too short and should have been replaced immediately, as per the facility's policy on providing adequate lighting.
A resident developed a stage four pressure ulcer on the left sacrum, but the facility failed to complete a Significant Change in Status Assessment (SCSA). The Minimum Data Set Coordinator did not consider the ulcer a significant change, contrary to the Director of Nursing's view. This oversight reduced the facility's ability to provide appropriate care based on the resident's condition.
A resident with a stage four pressure ulcer was inaccurately coded in the MDS as having a deep tissue injury and unstageable wound, despite assessments indicating otherwise. The MDS Coordinator made this decision, believing these conditions were worse than a stage four PU, which contradicted the facility's policy. This misclassification could lead to inadequate wound care management.
A facility failed to create a comprehensive care plan for a resident with a pathological fracture who required a leg immobilizer. The absence of a care plan was confirmed by a nurse and the DON, who acknowledged that the plan should have been developed promptly to ensure timely implementation. The facility's policy mandates comprehensive care plans with measurable objectives, which was not followed in this instance.
A resident with a pathological fracture of the right distal femur was observed using a knee/leg immobilizer without a physician's order. The facility's policy requires immediate recording of physician orders, which was not followed, leading to a deficiency in meeting professional standards of care.
A resident with upper extremity weakness and cerebral infarction was not assisted with wearing hearing aids as ordered, leading to communication difficulties. Observations confirmed the resident was not wearing the aids, which were out of reach, and staff failed to provide necessary assistance.
The facility failed to follow infection control practices for two residents. A nurse did not wear the required N-95 mask for a resident on droplet precaution due to COVID-19, and Enhanced Barrier Precautions were not implemented for a resident with a stage three pressure ulcer. The absence of proper PPE and EBP signage increased the risk of infection spread.
A facility failed to ensure a call light was within reach for a resident with dementia, who required assistance with personal care. During an observation, the call light was found clipped to the head side of the mattress, behind the resident, making it inaccessible. A CNA confirmed the call light was out of reach, and the DON acknowledged the potential for missed care and falls. The facility's policy requires call lights to be accessible to residents.
A resident with respiratory failure and coronavirus disease was transferred to the hospital due to a significant change in condition, but the facility failed to complete required documentation, including a change of condition form, hospital transfer form, and family notification. Interviews with staff confirmed the absence of these documents, which is against the facility's policies.
Unsecured Computer Screen Exposed Resident Health Information
Penalty
Summary
The facility failed to keep confidential resident health information secure when a Licensed Nurse left a computer screen unlocked and accessible during medication pass observations. On 9/7/25 at 9:00 a.m., the nurse left the computer unlocked and unattended while she went to clarify an order, and at 9:08 a.m. the same nurse again left the screen unlocked and accessible when she entered a resident's room. During an interview later that day, the nurse confirmed she had left the computer unlocked and unattended on both occasions. The Director of Nursing stated that nursing staff were expected to lock the cart and screen to hide residents' information so personal health information would not be exposed. The facility's policy on Electronic Medical Records states that only authorized persons with a password and user ID may access the system and that the facility will make reasonable efforts to limit the use or disclosure of protected health information.
Medication Administration and Order Clarification Deficiencies
Penalty
Summary
A lidocaine 5% patch was applied to Resident 82’s lower back during a medication pass observation, but the Assistant Director of Nursing did not sign or date the patch after applying it. During interview, the ADON confirmed she was supposed to sign and date the patch after application but did not do so because she did not have a marker. The Director of Nursing stated nurses were expected to date and sign patches upon administration to ensure the patch was changed correctly and to prevent medication errors. The facility policy for transdermal patch application stated to label the patch with the date and nurse’s initials. During a medication pass observation, Licensed Nurse 4 entered Resident 85’s room and began medication administration without properly identifying the resident. In interview, LN 4 stated she missed identifying the resident before giving medication and said she normally would ask for the resident’s name and date of birth before administering medications. The DON stated nurses were expected to verify resident identity before medication pass and could use the MAR picture and the name posted by the resident’s door. The facility’s medication administration policy stated the individual administering medication verifies the resident’s identity before giving medications and checks the label three times to verify the right resident. LN 4 also prepared and administered Resident 85’s spironolactone without gloves. During review and interview, LN 4 confirmed the resident’s record did not identify spironolactone as hazardous, while the bubble packet label contained the word HAZAR to indicate it was hazardous. LN 4 stated she did not know spironolactone was hazardous and required gloves. The consultant pharmacist stated gloves would be required for handling spironolactone, especially for staff who could be pregnant, and said staff were made aware of hazardous drugs by bottle labels and by his recommendation to add them into charts. In addition, Resident 7 had two PRN pain medication orders, acetaminophen 500 mg every six hours as needed and hydrocodone-acetaminophen 5-325 mg every six hours as needed, and the DON stated nursing staff should have clarified the orders with the physician to determine when each medication was appropriate and to include pain scale parameters.
Controlled Medication Documentation and Destruction Deficiencies
Penalty
Summary
Controlled medications were not accurately documented during medication administration. During a medication pass, the ADON administered Oxycontin ER 10 mg to a resident for pain management but did not document removal of the medication on the Controlled Drug Record (CDR) before administration. The ADON confirmed the omission and stated the process should be to sign the CDR prior to administration. The facility policy required the licensed nurse to immediately enter the date, time, amount administered, and signature on both the accountability record and the MAR after the medication is administered. For two residents, controlled substances were signed out of the CDR but the corresponding administrations were not documented on the MAR. One resident had Valium 5 mg removed from the medication cart, but the MAR did not show the dose as given; the DON confirmed the discrepancy and stated it may have been documented on the incorrect CDR because the timing matched the bedtime dose. Another resident had morphine sulfate 15 mg removed from the cart, but the MAR did not document the administration. The facility policies required the nurse administering the medication to record the resident name, medication name, strength, dose, time, method, and signature on the MAR and accountability record. The facility also did not demonstrate adequate safeguards for controlled substance destruction and chain of custody. The DON described a process in which controlled medications and the CDR were brought to her office, signed off after counting, and then stored in a locked drawer until the consultant pharmacist arrived for monthly or every-other-month destruction. The consultant pharmacist stated there was no system to identify whether controlled substances were diverted between being locked in the DON’s cabinet and the time of destruction, and confirmed the process did not limit the potential for diversion because of lack of accountability and documentation. The facility policy stated controlled medication destruction is to be done in the presence of a pharmacist and an RN and documented on a disposal form or disposition log.
Medication Administration Errors During Pass
Penalty
Summary
Medication administration errors occurred during observation of a medication pass for two residents, resulting in a 14.81 percent error rate with four errors out of 27 opportunities. For one resident, the ADON prepared and administered Senokot 8.6 mg even though the physician’s order was for Senna Plus oral tablet 8.6-50 mg, two tablets by mouth once daily for bowel management and to hold for loose stool. The ADON later confirmed the order was for Senna Plus and that Senokot had been given instead. For another resident, an LN administered carvedilol 3.125 mg and Jardiance 10 mg without food even though both orders specified to give with a meal. The LN stated she did not know when the resident last ate and did not verify it before administration. The same LN also administered only one puff of Symbicort inhaler even though the order was for two puffs twice daily. The LN confirmed the order required two puffs, and the facility policy stated medications are to be administered in accordance with prescriber orders, including any time frame.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure multi-dose medications were labeled correctly after use with an open date. During a medication pass observation with LN 4, Resident 85’s Budesonide/Formoterol (Symbicort) inhaler and Tiotropium (Spiriva Respimat) inhaler were found without an open date. During a concurrent medication cart audit of Cart 2 with LN 2, three of five Refresh Tears eye drops did not have resident-specific labeling, and LN 2 confirmed the labeling was missing. The facility’s Medication Labels policy stated that labels are permanently affixed to prescription containers and that if a label does not fit directly onto the product, the resident’s name must be maintained directly on the actual product container. The facility also failed to store medications according to manufacturer specifications and to secure OTC medications. During the Cart 2 audit with LN 2, budesonide inhalation suspension ampules were found outside of their foil packaging, even though the manufacturer’s labeling stated that once the foil envelope is opened, the vials should be used within 2 weeks and returned to the foil envelope to protect them from light. Fluticasone furoate/vilanterol inhaler was also found without an opened date, and LN 2 confirmed it should have had one. In addition, during observation of the central supply room, the door was wide open and unattended while OTC medications were stored on shelves in the room. SC confirmed the room should not have been left unlocked and unattended, and the ADM and DON confirmed the door should have been locked and secured.
Failure to Follow Pureed Rice Recipe
Penalty
Summary
The facility failed to follow the recipe for pureed rice for three residents: a resident admitted in 2023 with a fortified diet order for pureed texture and nectar thick consistency, a resident admitted in 2024 with dysphagia and an order for a regular large portions diet with pureed texture and thin liquids, and a resident admitted with dysphagia who had an order for no added salt, consistent carbohydrate, pureed texture, and nectar thick consistency. The lunch menu for the day included curry lemon chicken, garlic rice, peas with onions, wheat roll, and ice cream, and the facility's recipe for pureed starch rice called for six to 12 ounces of warm milk to be added to six servings of rice. During a concurrent observation and interview, a dietary staff member was observed preparing six servings of rice for pureeing and stated she was making six servings of rice before placing the cooked rice in a blender. Heated milk was to be added in increments using a 1/3 cup scoop to obtain the desired pureed consistency, but she added three unmeasured scoops of milk and stated she should have followed the recipe and measured the amount of added milk. The Dietary Services Supervisor retrieved the recipe binder and showed the pureed rice recipe, and the Registered Dietician later stated the staff member did not measure three of the scoops of milk added to the rice and that it was uncertain what the partial scoops added up to in total.
Expired and Unlabeled Food Stored; Cooked Meat Cooling Procedure Not Followed
Penalty
Summary
The facility failed to properly prepare and store food for a census of 67 residents when expired and unlabeled food items were found during observation and interview. In dry storage, surveyors found one unopened package of hamburger rolls removed from the freezer on 8/27/25 with a use-by date of 9/3/25, one opened package of wheat bread that was unlabeled and undated, and two opened packages of pasta opened on 9/1/24 with a use-by date of 9/1/25. In the walk-in refrigerator, surveyors found 20 heads of celery with wilted leaves and an expiration date of 9/4/25. The Assistant Dietary Manager and Dietary Services Supervisor confirmed the items were expired and should not be served to residents. The facility also failed to follow its cool down procedure for cooked meat. During observation, a staff member was cutting turkey roasts on the meat slicer for the residents' lunch entree. Review of the Cool Down Log showed that on 9/6/25, at the two-hour point in the cooling process, the temperature of the turkey roasts was documented at 80 F and the cooling process was continued. The staff member and Dietary Services Supervisor stated that 80 F was too high for the two-hour cool down mark and that the turkey needed to be discarded. The facility's policy required cooked potentially hazardous food to cool from 140 F to 70 F within two hours and to be discarded if above 70 F after more than 2 hours into cooling.
Improper Garbage Dumpster Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse when a kitchen garbage dumpster was observed with two gaping, warped lids during a concurrent observation and interview with the Registered Dietician and the Maintenance Plant Director. One dumpster lid was rounded and bowed, leaving a lengthy 3-inch gap between the lids and the top rim. The Registered Dietician stated this was a pest problem because rodents and insects had access inside the dumpster. The Maintenance Plant Director stated he had ordered a new dumpster but had no documentation of the order with the disposal company. A review of the facility's Garbage and Trash policy dated 2023 stated that adequate, clean, vermin-proof areas must be provided for the storage of garbage and that the lids are closed.
Infection Control Failures in Laundry, Resident Care, and Medication Pass
Penalty
Summary
The facility failed to maintain infection prevention and control practices in multiple areas of care and the environment. In the laundry room clean area, multiple surfaces had an accumulation of a gray powdery substance, including a cart holding clean linens covered with pink mesh material, a portable fan on the folding table, and the area behind three dryers. The Environmental Services Supervisor observed the condition and confirmed the accumulation, stating it was neither clean nor good for residents and staff and that they had not paid much attention to it. Facility policy required clean linen to remain hygienically clean and environmental surfaces to be cleaned and disinfected. Resident 73, who had COPD and pulmonary embolism and was receiving ipratropium-albuterol via nebulizer every six hours, had a nebulizer mask sitting on top of the nightstand without a bag. During observation, the Infection Preventionist confirmed the mask was not stored in a bag and stated it should always be inside a bag to prevent infection. The facility policy for respiratory therapy stated the nebulizer circuit should be stored in a plastic bag between uses. Resident 34, who had neutropenia, a lung transplant, squamous cell carcinoma of the scalp, and a sacral pressure sore, was receiving mycophenolate mofetil for immunosuppression and had daily dressing changes ordered for the scalp surgical site and pressure sore. During observation, a large soiled dressing dated 9/5/25 was found in the toilet in the resident’s room after staff had assisted him. LN 5 stated it was unacceptable and that the dressing should have been discarded in the biohazard receptacle in the room. The Infection Preventionist later stated dressings should never be discarded in the toilet and that the assistant should have used the biohazard bin instead. Additional infection control failures were observed during medication administration and equipment care. LN 4 and LN 3 were observed with approximately one-inch-long acrylic fingernails while preparing and administering medications, and LN 3 acknowledged she knew she was not supposed to have them. LN 4 was also observed disinfecting a BP cuff and stethoscope with germicidal wipes without gloves, despite stating she was expected to wear gloves. LN 4 also used a single-use Styrofoam tray during med pass for Resident 85 and returned the tray to the medication cart after use instead of discarding it. Facility policy required short, natural fingernails for direct-care staff, gloves when cleaning medical equipment, and disposal of single-use items after one use.
Failure to Notify Responsible Parties of Change in Condition and Appointments
Penalty
Summary
The facility failed to ensure that two residents and their responsible parties were informed of changes in condition and medical appointments. One resident was admitted with dementia and Alzheimer’s disease, and her son was listed as the responsible party. The resident’s record showed two ENT follow-up appointments were completed for ear infections, but the medical record did not indicate that the responsible party was notified of those appointments or the treatment plan. During interview, the responsible party stated the resident was supposed to be seen by an ENT for follow-up and had not been seen. Another resident was admitted with cerebral infarction and vascular dementia, and her MDS showed a BIMS score of 3 out of 15 with severe memory impairment. The resident’s responsible party stated she was concerned that she was not notified after the resident’s fall that resulted in a right foot injury. The medical record showed the responsible party was not notified after the change in condition, and although the change of condition form indicated a call was made without response, there was no documentation of a follow-up call or contact with another family member. The ADON reviewed both records and confirmed there were no notifications documented for the ENT appointments, treatment plan, or the change in condition.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain privacy for one resident with a urinary catheter when the catheter collection bag had no privacy cover. Resident 82 was admitted in August 2025 with diagnoses including acute cystitis and neuromuscular dysfunction of the bladder. Her MDS dated 9/3/25 showed a BIMS score of 12 out of 15, indicating moderate memory impairment, and her TAR dated 9/25 included an order to monitor her urinary catheter. During a concurrent observation and interview on 9/7/25 at 1:20 p.m., Resident 82 was sitting in her wheelchair at her bedside table eating lunch, and her urinary catheter bag was attached beneath the seat without a privacy cover. Resident 82 stated she had never had a private cover for the urine collection bag since admission and wanted one. A CNA later confirmed the resident did not have a privacy cover and stated she should have one. The Infection Prevention Nurse stated urinary catheter bags should always be covered to maintain residents' privacy. The facility policy titled Dignity, revised in 2/21, stated that demeaning practices and standards of care that compromise dignity are prohibited and that staff are expected to help residents keep urinary catheter bags covered.
Inaccurate MDS Assessment of Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess Resident 5’s skin condition when the MDS incorrectly indicated that the resident had no pressure ulcers. Resident 5 was admitted with a diagnosis of pressure ulcers, and during observation the resident had a wound VAC operating at the bedside. The resident’s Order Summary Report showed treatment orders for two stage four pressure ulcers, one on the sacrum and one on the left gluteal crease, along with the wound VAC. A review of Resident 5’s MDS showed no documented pressure ulcers in the skin condition section. During interview and record review, the MDSC confirmed that Resident 5 had pressure ulcers since admission and stated the MDS dated 6/2/25 was inaccurately coded based on the TAR and treatment notes. The NC also reviewed the records and stated the MDSC should have ensured assessments were documented accurately to ensure proper delivery of care to residents.
Missed Scheduled Shower for Resident with Fractures
Penalty
Summary
The facility failed to accommodate the needs of one of 26 sampled residents when Resident 76 was not given a shower as scheduled. Resident 76 was admitted in September 2025 with diagnoses of right femur fracture and vertebra fracture. During an interview on 9/7/25, Resident 76 stated she felt uncomfortable because she had not taken a shower since admission to the facility. A review of the Skilled Nursing Shower Assignment, updated on 8/18/25, showed Resident 76 was scheduled for morning showers on Monday, Wednesday, and Friday. CNA 2 stated residents were assisted with showers in the morning per schedule and that CNAs were required to complete a shower tracking sheet and document it in the computer to notify the LN whether the shower was given or refused. LN 1 confirmed there was no documented shower sheet for Resident 76. The DSD reviewed progress notes and bathing task documentation and stated the notes did not show Resident 76 refused a shower the prior week, and the assigned CNA did not provide the shower. The ADM stated CNAs were expected to provide showers as scheduled unless residents refused.
Respiratory Equipment Not Changed on Schedule
Penalty
Summary
Proper respiratory care was not provided for Resident 10 when the facility failed to ensure respiratory equipment was maintained according to policy and professional standards of practice. Resident 10 was admitted in February 2024 with a diagnosis of respiratory failure with hypoxia and had an order for oxygen via nasal cannula to keep oxygen saturation at 92 percent. During a concurrent observation and interview, a nebulizer machine with tubing/mouthpiece and a nasal cannula were observed at the resident’s bedside, and the Licensed Nurse confirmed both tubings were last replaced on 8/28/25 as shown by the label. The nurse stated the tubings were not changed in seven days. The DON stated staff were expected to follow the facility’s respiratory equipment policy, which directed that the administration set-up for medication nebulizers/continuous aerosol be discarded every seven days.
Failure to Provide Scheduled Showers Compromises Resident Dignity
Penalty
Summary
A resident with diagnoses including spinal stenosis, weakness, gait and mobility abnormalities, and lower back pain was admitted to the facility and required assistance with activities of daily living, including bathing. According to the resident's Minimum Data Set and care plan, staff were responsible for providing this assistance. The resident was scheduled to receive showers on specific days, as indicated by the facility's shower schedule. However, documentation and interviews revealed that the resident did not receive a shower for five consecutive days, receiving only a bed bath at the beginning of this period and a shower at the end. The resident reported feeling unclean and expressed dissatisfaction to CNAs about not receiving a shower, specifically mentioning that her hair became matted and dirty, which negatively affected her well-being. Staff interviews and record reviews confirmed that the resident's scheduled showers were missed and not documented as refusals. The Director of Staff Development and the DON both acknowledged that the resident did not receive bathing services as scheduled and that this was not in accordance with facility policy. The facility's policy emphasized the importance of promoting residents' sense of well-being, satisfaction, and self-worth, which was not upheld in this instance. The failure to provide scheduled showers was identified through observation, interviews, and record review, and was recognized as a lapse in maintaining the resident's dignity.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen microwave was found to be dirty with dried liquid splashes, which the Dietary Supervisor confirmed should have been cleaned. Additionally, several metal sheet pans were improperly stored while still wet, which the Dietary Supervisor acknowledged could lead to bacterial growth. Produce items, including potatoes and onions, were found to be spoiled and not discarded, with the potatoes exhibiting mold and a foul odor, and the onions attracting gnats and having a mushy liquid at the bottom of their storage container. Furthermore, a dietary aide was unable to correctly verbalize the procedure for manual dishwashing using a 3-compartment sink, incorrectly stating the immersion time for sanitizing dishes. The Dietary Supervisor also admitted to not knowing the correct immersion time due to a recent change in supply vendors. These deficiencies in food storage, preparation, and staff knowledge posed a potential risk of food-borne illness to the 59 residents receiving food from the kitchen.
Improperly Secured Garbage Dumpsters
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors due to improperly secured garbage dumpsters. During an observation and interview with the Dietary Supervisor, it was noted that all three dumpsters outside the facility had bent and deformed lids, which prevented them from being securely closed. This condition was confirmed by the Dietary Supervisor, who acknowledged the need for new trash bins and the importance of tightly closed lids to prevent pest issues. The facility's policy requires all food waste to be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and the FDA Food Code mandates that outside receptacles for refuse containing food residue must have tight-fitting lids. The failure to comply with these standards posed a potential risk for pest infestation and disease spread.
Failure to Follow Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to adhere to prescribed therapeutic diets for residents during lunch meals on two consecutive days. Resident 257, who was on a dysphagia mechanical texture diet, received incorrect food textures on both days. On the first day, the resident was served puree zucchini instead of the required chopped and mashable zucchini. On the following day, the resident received a puree apple bread pudding instead of the specified chopped and soaked version. These discrepancies were confirmed by the Registered Dietitian, who acknowledged that the menu was not followed as per the facility's spreadsheet. Additionally, Resident 21, who was on a controlled carbohydrate diet, received a full slice of garlic breadstick instead of the prescribed half slice, which could potentially affect blood sugar levels. Resident 20, on a finger food diet, was served a regular apple bread pudding in one piece rather than the required four pieces. The Dietary Supervisor confirmed the error in serving size. These failures in following the dietary plans had the potential to compromise the medical and nutritional status of the residents involved.
Failure to Maintain Homelike Environment Due to Broken Light Chain
Penalty
Summary
The facility failed to provide a homelike environment for Resident 42, as observed during a survey. The deficiency was identified when the chain used to operate the overhead light in Resident 42's room was found to be broken and unreachable, approximately three inches long. This issue was present since the resident's admission in early September 2024, as confirmed by Resident 42, who expressed that the broken chain prevented him from turning the light on or off independently. During observations and interviews, both a Licensed Nurse and the Director of Nursing acknowledged the problem, confirming that the chain was too short for the resident to reach and should have been replaced immediately. The facility's policy on maintaining a homelike environment, which includes providing comfortable and adequate lighting, was not adhered to in this instance.
Failure to Complete SCSA for Resident with Stage Four Pressure Ulcer
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who developed a stage four pressure ulcer on the left sacrum. The resident, admitted in August 2024 with diagnoses including morbid obesity and diabetes, was observed with a wound vacuum on her lower back. A Change in Condition note dated July 5, 2024, indicated the development of the stage four pressure ulcer, which was confirmed by the treatment nurse and diagnosed by the wound doctor. Despite this significant change in the resident's condition, the Minimum Data Set Coordinator (MDSC) did not complete the SCSA, as she did not consider the facility-acquired stage four pressure ulcer a significant change. The Director of Nursing, however, stated that a stage four pressure ulcer should be considered a significant change, and the SCSA should have been completed to reflect the resident's current status. This oversight decreased the facility's potential to provide appropriate care and services to the resident based on her status.
Inaccurate MDS Coding of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically regarding a pressure ulcer (PU). The resident, who was admitted with diagnoses including morbid obesity and diabetes, had a stage four PU on the left sacrum. Upon readmission to the facility after a hospital visit, the Treatment Nurse (TN1) confirmed the presence of the stage four PU. However, the MDS Quarterly Assessment inaccurately coded the wound as a deep tissue injury and unstageable, despite the skin assessment indicating it was a stage four PU. The MDS Coordinator (MDSC) decided to code the wound as a deep tissue injury and unstageable, believing these conditions were worse than a stage four PU. This decision was contrary to the facility's policy, which requires accurate resident assessments. The Director of Nursing (DON) confirmed that the MDSC should have coded the wound as a stage four PU to ensure appropriate wound care management. This misclassification had the potential to result in inadequate wound care for the resident.
Failure to Develop Comprehensive Care Plan for Resident's Leg Immobilizer
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 208, who was admitted with a diagnosis of a pathological fracture of the right distal femur. During an observation, the resident was seen wearing a right leg immobilizer while seated in a wheelchair. However, upon review of the resident's care plan, it was found that there was no documentation addressing the use of the leg immobilizer. This oversight was confirmed during an interview with a Licensed Nurse, who could not locate a care plan for the immobilizer, and the Director of Nursing, who acknowledged the absence of the care plan and stated that it should have been developed as soon as the order was received to prevent delays in implementation. The facility's policy requires a comprehensive care plan with measurable objectives and timetables for each resident, which was not adhered to in this case.
Failure to Obtain Physician Order for Knee/Leg Immobilizer
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for one of the sampled residents, Resident 208. Resident 208 was admitted in September 2024 with a diagnosis of a pathological fracture of the right distal femur. During observations on September 23, 2024, Resident 208 was seen using a right knee/leg immobilizer while seated in a wheelchair. Treatment Nurse 1 confirmed that the resident had been using the immobilizer since admission. However, upon review of Resident 208's Order Summary Report, Licensed Nurse 1 and the Director of Nursing found no physician's order for the use of the knee/leg immobilizer. The facility's policy requires that physician orders be signed, dated, and recorded immediately to ensure accurate delivery of care, which was not adhered to in this case.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with using hearing aids as ordered, which was an ancillary service required for the resident's care. The resident, who was admitted with diagnoses including weakness of upper extremities and cerebral infarction, was observed on multiple occasions without wearing his hearing aids. The resident reported that staff did not assist him in putting on the hearing aids, and he was unable to do so himself due to his physical limitations. Observations and interviews with staff, including a licensed nurse and the Director of Nursing, confirmed that the resident was not wearing his hearing aids as per the order. The hearing aids were found on the nightstand, out of the resident's reach, indicating a lack of assistance from the nursing staff. The facility's policy on assistive devices and equipment, which includes hearing aids, was not followed, leading to the resident's increased difficulty in hearing and communicating effectively.
Infection Control Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for two residents. For Resident 24, who was on droplet precaution due to a COVID-19 infection, Licensed Nurse 4 (LN 4) did not wear the required N-95 mask while providing care. Instead, LN 4 wore only a surgical mask while administering medications, despite the presence of a droplet precaution sign on the resident's door. This was confirmed during an interview with LN 4, who acknowledged the oversight. The Director of Nursing (DON) stated that staff are expected to follow proper infection control practices to prevent the spread of infection. For Resident 15, who had a stage three pressure ulcer, Enhanced Barrier Precautions (EBP) were not implemented. During an observation, it was noted that there was no EBP sign on the door, and no personal protective equipment (PPE) supplies were available in the designated drawer in the resident's room. LN 3 confirmed the absence of the EBP sign and supplies. The DON acknowledged that the missing EBP sign and protective supplies increased the risk of spreading infection to Resident 15, other residents, and staff.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 18. Resident 18 was admitted to the facility in February 2023 with diagnoses including dementia and a need for assistance with personal care. During an observation and interview on September 23, 2024, it was noted that Resident 18 was sitting in a chair next to her bed, and her call light was clipped to the head side of the mattress, behind her, making it inaccessible. Certified Nursing Assistant 1 confirmed that the call light was out of reach and stated that it should have been placed in front of Resident 18. The Director of Nursing acknowledged that the call light being out of reach could have resulted in missed care and potential falls, emphasizing that staff must ensure call lights are accessible to all residents. A review of the facility's policy and procedure titled 'Answering Call Light,' dated 2022, indicated that call lights should be accessible to residents. This oversight decreased Resident 18's potential to receive timely assistance from staff when needed.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident who was admitted with diagnoses including respiratory failure and coronavirus disease. During a record review, it was found that essential documentation, such as a change of condition (COC) form, a hospital transfer form, and family notification, was missing from the resident's chart after they were transferred to the hospital due to a significant change in condition. Interviews with a Licensed Nurse (LN) and the Director of Nursing (DON) confirmed the absence of these documents. The facility's policies require that a nurse notify the resident's representative and complete necessary documentation when there is a significant change in the resident's condition, which was not done in this case.
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What surveyors actually found near you
We read the 202 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Placerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Slope Health Center | 2.4 mi | ★★★★★ | 12 | 0 |
| The Pines At Placerville Healthcare Center | 2.5 mi | ★★★★★ | 16 | 0 |
| Folsom Care Center | 18.4 mi | ★★★★★ | 3 | 0 |
| Rock Creek Care Center | 18.5 mi | ★★★★★ | 9 | 0 |
| Auburn Ravine Healthcare Center | 19.2 mi | ★★★★★ | 19 | 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 June 2026) and official state health department websites.