Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pines At Placerville Healthcare Center during CMS and state inspections, most recent first.
Staff failed to follow infection control practices in several situations. A resident’s enteral feeding tube tip was left hanging from an IV pole without a protective cap, staff entered rooms under Contact Plus and Enhanced Standard Precautions without fully donning required PPE, and staff touched two residents’ lunch items with bare hands while assisting with meals. The DON, DSD, ADON, and staff confirmed the expected infection control practices were not followed.
A resident with dysphagia and a recent diet downgrade had a breakfast tray left within reach without staff present, despite orders for pureed texture, mildly thick liquids, and feed assist with breakfast. Another resident with CVA and aphasia had a call light that was looped around the bed rails and lodged between the mattress and bed frame, leaving it inaccessible despite a care plan to keep the call light within reach.
A facility failed to maintain a resident corridor in a clean, safe, and homelike condition when surveyors observed a hole in the ceiling with visible water damage, staining, and a black and white substance around the opening. An LN confirmed the condition and said it had not been reported in the maintenance log, and the DPO later confirmed the damage was caused by a leaking water pipe in the ceiling.
Failure to assess respiratory status, give ordered morphine correctly, and complete accurate weekly documentation. A resident with asthma and COPD had marked shortness of breath and a high RR, but the CNA did not report the change and the LN did not assess the resident before leaving the room, despite an active morphine order for SOB. Another resident with dementia received 1 mL of morphine instead of the ordered 2.5 mL for pain, and no med error report was completed. A third resident with an indwelling catheter had weekly summary documentation that incorrectly stated I&O was not being monitored and left urine assessment fields blank, despite the resident’s catheter-related care needs.
Medication administration errors exceeded the allowable rate when three errors were observed during a medication pass. An LPN administered fluconazole without shaking the bottle, another LPN crushed a pantoprazole DR tablet despite a do-not-crush order, and an LPN gave only 1 ml of ordered morphine instead of 2.5 ml. The DON confirmed the morphine dose error and that no medication error report had been submitted.
Expired medications were found stored in medication carts and a wound treatment cart, including an expired fluticasone/salmeterol inhaler, diclofenac gel, triamcinolone cream, and ketoconazole shampoo. An LPN confirmed the inhaler was expired and that use past the expiration date could reduce effectiveness, and another LPN confirmed the other products were expired and should be disposed of. The DON stated nursing staff should not keep expired medications in carts, and the facility policy required following manufacturer expiration dates for inhalers.
Resident rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 did not meet the required 80 sq. ft. per resident for multi-occupancy rooms. The rooms measured 228.55 sq. ft. for three residents, or 76.2 sq. ft. per resident. Staff reported they could provide care in the rooms, and residents said they had sufficient space, but the ADM confirmed the room dimensions did not meet the standard.
Failure to Protect Resident from Physical Abuse: A resident with dementia, severe cognitive impairment, and a history of combative behavior attempted to assault another resident after wandering and becoming agitated. Video footage and witness statements showed the resident grabbing, swinging at, and hitting the other resident on the arm and chest, and the other resident reported pain from being hit. The other resident also had dementia and severe cognitive impairment, and the DON confirmed residents are expected to be free from physical abuse and undesirable touching.
The facility did not designate a physician to serve as medical director, resulting in a lack of oversight and coordination for the implementation of resident care policies and medical care.
The facility failed to maintain safe room temperatures for several residents due to a broken HVAC system, resulting in discomfort. Despite being aware of the issue, the maintenance department delayed ordering floor heaters, and residents were left with inadequate heating solutions. Staff acknowledged the problem, but the facility's actions were insufficient to address the residents' needs.
The facility failed to meet food safety standards, with uncovered facial hair on dietary staff, an unclean juice machine, improperly stored wet utensils, and the use of unpasteurized eggs. Additionally, a dietary aide lacked knowledge of proper dishwashing procedures, highlighting training deficiencies.
A facility failed to accurately document controlled medications for four residents, leading to discrepancies between the MAR and CDR. Residents with chronic pain, osteoarthritis, peripheral vascular disease, and cancer had inconsistencies in the administration records of hydrocodone-acetaminophen and lorazepam. The DON acknowledged the importance of consistent documentation for accountability and proper medication timing.
A long-term care facility experienced a medication error rate of 17.95% due to improper administration of medications to four residents. Errors included late administration, incorrect dosages, and failure to follow prescribed methods. These issues were confirmed through observations and interviews with nursing staff and the DON.
The facility failed to follow prescribed dietary menus for residents on therapeutic diets during lunch meals. Residents on CCHO, DM texture, and FF diets received incorrect food items, such as full slices of garlic bread, regular rice and beans, and inappropriate desserts. These discrepancies were confirmed by the Dietary Supervisor and Registered Dietitian, potentially compromising the residents' medical and nutritional status.
The facility failed to accommodate the food preferences of five residents during meal service, as meal tickets were not followed. Residents did not receive specific food items as indicated, such as cottage cheese, side salad with blue cheese dressing, and ice cream. Interviews with the Dietary Supervisor and RD confirmed these findings, acknowledging the kitchen staff's failure to provide the food items as indicated. The facility's policy stated that residents' food preferences should be adhered to.
The facility failed to implement proper infection control practices, including sanitizing medical equipment between uses and providing nail care for residents. Additionally, a CNA did not adhere to neutropenic precautions for a resident with multiple myeloma, failing to wear protective equipment. The facility lacked a specific policy for neutropenic precautions.
The facility did not meet the required space standards for 10 resident rooms, with several rooms providing less than the mandated 80 square feet per resident. Despite the space being sufficient for assistive devices and care provision, the Administrator confirmed the shortfall. Residents reported the space as adequate for their needs, and a waiver continuation was recommended.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in care. One resident's narcotic pain medication was not coded, and another's pressure ulcers were omitted from their assessments. These oversights were confirmed by the DON and MDSC during record reviews.
A resident's anticoagulant care plan was not updated in a timely manner after a medication change from rivaroxaban to apixaban. The facility's policy requires care plans to be reviewed and revised quarterly or upon receiving new orders, but this was not done, impacting the facility's ability to provide effective, resident-centered care.
The facility failed to provide proper respiratory care for two residents with COPD. One resident did not receive continuous oxygen therapy as prescribed, using it only at night with a CPAP machine. Another resident missed nebulizer treatments on two occasions, leading to shortness of breath and distress. The MAR lacked documentation for these treatments, and staff confirmed the absence of records. The DON and DSD highlighted the need for adherence to physician orders and accurate documentation.
A facility failed to follow a physician's order for fluid restriction for a resident with stage four chronic kidney disease who was dependent on dialysis. Despite an order limiting fluid intake to 1000 ml per day, three water pitchers were found on the resident's bedside table. This oversight was confirmed by a nurse and the ADON, who emphasized the importance of adhering to fluid restrictions to prevent complications. The facility's policy also stated that water pitchers should not be placed in rooms of residents with fluid restrictions.
A facility failed to adequately monitor a resident's behaviors while on quetiapine for dementia with agitation. The MAR required behavior monitoring every shift, but the night shift only had yes or no options, lacking quantification. Interviews with staff confirmed this was ineffective for assessing medication effectiveness and planning for GDR.
A facility failed to label two respiratory medications with open dates, as observed during a survey. A nurse confirmed the medications were unsealed and undated, and the DON stated that staff were expected to label medications to track expiration. This oversight increased the risk of administering expired medications.
A resident with impaired vision and dysphagia was not assisted during meals as required by her care plan, despite having an order for feeding assistance. Observations and interviews revealed that staff failed to provide necessary help, which was confirmed by the DON and the Director of Rehabilitation. This oversight contravened the facility's policy on meal assistance.
A resident with severe cognitive decline and a history of aggressive behavior physically assaulted another resident in an LTC facility. The incident, witnessed by a CNA, involved the resident punching another in the stomach. Despite having a care plan to manage aggressive behavior, the facility failed to prevent this altercation, which was confirmed by the DON and Administrator.
The facility failed to ensure that two residents were treated with dignity and respect. One resident had to wait three hours on a bedpan for assistance, while another resident's call light was not accessible, leading to delays in receiving help. The facility's policies on answering call lights and promoting dignity were not followed.
A resident with cognitive impairment and at risk for elopement left the facility unnoticed due to non-functional or semi-functional wanderer monitoring systems on exit doors. The resident's care plan and physician's order for a wander guard were not followed, leading to the resident's fall and injuries. Staff interviews revealed that door alarms were either not functioning or had low sound levels, and there was a lack of adherence to facility policies for monitoring and maintaining the wanderer monitoring system.
Infection Control Failures During Tube Care, Precaution Entry, and Meal Assistance
Penalty
Summary
The facility failed to maintain infection control practices for a census of 89 when the tip of Resident 6’s enteral feeding tube was observed hanging from the IV pole without a protective cap. Resident 6 was admitted with diagnoses including gastrostomy and quadriplegia, and the order summary indicated the enteral feeding tubing was to be changed every 24 hours during the evening shift. During observation, the tube tip was not connected to the resident but remained attached to the formula line without a cap. A LN stated the tip should have had a protective cover to maintain a closed system and reduce infection risk, and the DON stated the tip should have had a sterile cap when not in use; if it did not have a cover, the tubing had to be discarded and replaced entirely because using an uncovered tip could lead to infection. The facility also failed to follow infection prevention protocols when staff entered resident rooms under precautionary signage. A NAT was observed in a room with posted Contact Plus precautions wearing gloves only and without the required gown while handing snacks to residents; the NAT then exited the room, retrieved an item from the snack cart without changing gloves, and handed it to another resident. The NAT stated she had not noticed the signage and acknowledged she should have fully donned a gown and checked with the nurse before entering. The DSD stated Contact Plus precautions required staff to fully gown and glove before entering and to wash hands with soap and water before entering and after exiting. In a separate observation, a CNA entered a room with Enhanced Standard Precautions wearing gloves but no gown and assisted a resident with emptying a urinal; the CNA stated he should have followed protocol and worn a gown before entering, and the ADON confirmed staff were expected to fully comply with precautionary signage and required protective measures. The facility further failed to follow infection control practices during meal assistance when staff touched residents’ food with bare hands. Resident 52 and Resident 17 both had orders indicating they required assistance with eating meals, and each was observed in the dining room receiving lunch consisting of a hamburger and French fries. A CNA touched both the burger and fries with bare hands while assisting Resident 52, and a rehab aide did the same while assisting Resident 17. Both staff members confirmed they touched the food items with their hands. The DSD stated staff should not touch resident food with bare hands for infection control reasons and should use some type of barrier or a fork to pick up the food.
Meal Supervision and Call Light Accessibility Failures
Penalty
Summary
The facility failed to accommodate resident needs for two sampled residents when a breakfast tray was left within reach without staff present for a resident with dysphagia and a history of pneumonitis due to inhalation of food and vomit. The resident’s MDS indicated the BIMS could not be conducted, the resident was rarely or never understood, and the cognitive skills for daily decision-making score was 2, indicating moderately impaired decision-making requiring cues and supervision. The resident’s order summary listed a pureed texture, mildly thick consistency, and feed assist for breakfast. During observation, the resident’s breakfast tray was uncovered and within reach without staff present. A CNA stated the resident could eat independently with supervision but had left to assist another resident. An LN stated the resident required both supervision and assistance during meals because of aspiration risk and was undergoing a feeding trial. The SLP stated staff were required to supervise the resident during meals and that the resident’s diet had recently been downgraded from minced and moist to pureed, with education provided to staff regarding diet and swallow precautions. The facility also failed to keep another resident’s call light within reach. The resident had diagnoses including CVA and aphasia, was documented as capable of making own decisions, and had a care plan directing staff to keep the call light within reach. During observation, the resident was lying in bed crying and grimacing, and when asked for help, nodded. The resident attempted to reach the call light cord, which was looped around the bed rails, but could not pull it because the button was lodged between the mattress and bed frame. A CNA and LN confirmed the call light was not properly positioned, and the ADON stated staff were expected to ensure call lights were within reach before leaving the room.
Ceiling Damage and Water Intrusion in Resident Corridor
Penalty
Summary
The facility failed to maintain the physical environment in a clean, safe, and homelike condition when a hole was observed in the ceiling of one of five resident corridors containing 15 resident rooms. The ceiling around the hole showed visible water damage, including staining and deterioration consistent with moisture intrusion from a pipe above the ceiling, and the area also had a black and white substance surrounding the opening. During observation and interview, LN 7 confirmed the ceiling hole, water marks, and black and white substance, and stated the condition should have been reported to maintenance and should not have been present. LN 7 also confirmed the issue had not been entered in the facility maintenance log. The DPO later confirmed the finding had not been reported, acknowledged the damage was caused by water intrusion and a leaking water pipe in the ceiling, and stated he was responsible for keeping the facility in good repair. The ADM also confirmed the findings and stated the facility should be maintained in good repair and condition.
Failure to Assess Respiratory Status, Administer Ordered Morphine, and Complete Accurate Weekly Documentation
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality in three separate situations involving Resident 12, Resident 60, and Resident 92. Resident 12 was admitted with asthma and COPD and had orders for Morphine Sulfate oral solution 100 mg/5 mL, 0.25 mL by mouth every 2 hours as needed for mild pain or shortness of breath. The care plan directed staff to administer medication as ordered and to observe for clinical changes including respiratory distress. During observation, Resident 12 was noted to have a respiratory rate of about 36 breaths per minute with accessory muscle use and mouth breathing, but the CNA who assisted with care did not report the increased respiratory rate or shortness of breath to the supervising LN. The LN later entered the room to change the scopolamine patch but left without assessing the resident’s respiratory rate or shortness of breath, despite the active morphine order for respiratory symptoms. Resident 60, who had dementia and type 2 diabetes mellitus, had an order for Morphine Sulfate oral solution 10 mg/5 mL, 2.5 mL by mouth every 6 hours as needed for moderate to severe pain, with instructions to hold for respiratory rate less than 12. The resident’s EMAR showed that 2.5 mL was administered for pain rated 5/10, but the medication administration note documented that only 1 mL was given. During interview and record review, the LN acknowledged that 1 mL had been administered instead of the ordered 2.5 mL and stated that this was a medication error. The LN also confirmed that no medication error report had been completed, and the DON stated that licensed nurses were required to follow physician orders and that the error occurred when the smaller dose was given. Resident 92, who had a history including stroke with right-sided weakness, inability to urinate, urinary retention, and urinary tract infections, had an indwelling catheter order and a care plan that required monitoring urine for sediment, cloudiness, odor, blood, and intake and output as indicated. The weekly summary notes for two weeks documented that the resident was not on I&O monitoring, and the sections for intake, output, urine color, consistency, odor, clarity, skin turgor, edema, and mucous membranes were left unanswered. The DON stated that all residents were on I&O monitoring and confirmed that the weekly summary entries were not accurate for a resident with an indwelling catheter. Hospital records later showed that the resident was diagnosed with a urinary tract infection associated with an indwelling catheter.
Medication administration errors exceeded the allowable rate
Penalty
Summary
The facility did not ensure the medication error rate remained below 5% during a medication pass for a census of 89. Surveyors observed three medication errors out of 29 medication administration opportunities, resulting in a 10.34% medication error rate. The errors involved Resident 95 and Resident 60 and were identified through observation, interview, and record review. Resident 95 was admitted with diagnoses including candidal esophagitis and GERD. During a concurrent observation and interview, Licensed Nurse 3 prepared and administered 10 ml of fluconazole via G-tube without shaking the bottle first, even though the pharmacy label directed, "SHAKE WELL." After administration, LN 3 confirmed that fluconazole should be shaken prior to being given. In a separate observation, Licensed Nurse 5 crushed Resident 95's pantoprazole delayed-release tablet before administering it, despite the physician order stating, "Do Not Crush." LN 4 and LN 5 later confirmed that pantoprazole should not have been crushed. Resident 60 was admitted with diagnoses including dementia and type 2 diabetes mellitus. Her order for morphine sulfate oral solution directed 2.5 ml by mouth every 6 hours as needed for moderate to severe pain. The EMAR showed the medication was administered for pain rated 5/10, but the medication administration note documented only 1 ml given. During interview and record review, LN 7 acknowledged that 1 ml was administered instead of the ordered 2.5 ml and stated that this was a medication error and that no medication error report had been completed. The DON also confirmed that the incorrect dose constituted a medication error and that no medication error report had been submitted at the time the variance occurred.
Expired Medications Stored in Medication and Wound Carts
Penalty
Summary
The facility failed to implement its medication storage policy when expired medications were found stored in medication carts and available for use for a census of 89. During observation and interview, medication cart two contained an expired fluticasone propionate/salmeterol 250 mcg/50 mcg inhaler with an open date of 1/4/26, even though the manufacturer box indicated the product should be discarded one month after opening. The inhaler was stored with other inhaled medications, and LN 2 confirmed it was expired and stated that using an inhaler past its expiration date could lead to a loss of effectiveness. During a separate observation and interview, expired medications were also found in the wound treatment cart, including two diclofenac sodium 1% gel tubes, a triamcinolone 0.1% cream, and a bottle of ketoconazole 2% shampoo. LN 6 confirmed the medications were expired and being stored in the cart and stated that expired medications should be disposed of. The DON later stated that nursing staff should not store expired medications in medication carts and expects nursing staff to dispose of expired medications. The facility policy titled Medication Labeling, revised 8/24, stated that labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices, and that the manufacturer’s expiration date for inhalers should be followed.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure 9 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16) met the required 80 square feet per resident for multiple-occupancy rooms. The rooms were measured at 228.55 square feet for three residents, which equaled 76.2 square feet per resident. The report states this condition affected 27 residents living in these rooms, out of a census of 89 residents. During the survey, observations in the affected rooms showed there was space to store assistive devices such as wheelchairs and walkers, and staff were able to provide care. An LN stated care could be given in the rooms without problems, and a CNA was observed using a sit-to-stand device to move a resident from the room to the shower room without needing to move items. The DPO stated no changes had been made to the size or layout of the resident rooms, and the ADM confirmed the room dimensions and that each resident should have 80 square feet. Residents interviewed in the affected rooms stated they felt they had sufficient space to receive care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident swung his arms several times at another resident and contacted the other resident’s upper body. The resident who was struck reported pain from being hit. The resident who initiated the incident had diagnoses including dementia, anxiety, depression, restlessness, and agitation, and his MDS indicated severely impaired cognition. His care plan identified a history of being physically combative and abusive, including striking out and grabbing, and nursing notes described him as disoriented, delusional, aggressive, and unable to be redirected. On the evening of the incident, nursing documentation stated that the resident attempted elopement, was redirected, and then was seen attempting to assault another resident while staff were separating them. Additional nursing notes stated that he was restless, angry, combative, and agitated, and that he attempted to assault another resident and could not calm down. The resident was transferred to acute care after the event. The other resident involved had diagnoses including cerebral edema, dementia, and depression, and her MDS indicated severely impaired cognition. Her care plan identified memory impairment and risk for behavioral problems. Security camera footage showed the resident in the hallway with the other resident seated in a wheelchair. The other resident extended her arm and grabbed his hand, and he reacted by pulling back, reaching toward her neck, and swinging his arms, contacting her arms several times before staff separated them. A CNA stated she saw him hit the other resident in the chest area. The other resident stated that he twisted her hand and hit her on the chest and that it hurt. Another resident stated she saw him push back on the other resident and hit her on the arm and chest, describing it as a hard hit. The DON confirmed the expectation that residents be free from abuse, including physical abuse and undesirable touching, and the facility policy stated residents have the right to be free from abuse by anyone, including other residents.
Failure to Designate Medical Director for Resident Care Policies
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a physician to serve as the medical director. This physician is responsible for the implementation of resident care policies and the coordination of medical care within the facility. The absence of a designated medical director resulted in a lack of oversight and coordination for resident care policies and medical services, as required.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable room temperature for four residents, as observed during a survey. The room temperatures in the facility's back hallway were recorded below the acceptable range, with temperatures ranging from 67.1 to 70.2 degrees Fahrenheit. The Maintenance Director confirmed these low temperatures and acknowledged that the HVAC system was broken, affecting rooms 33-38. Despite being aware of the issue since early December, the maintenance department did not provide alternative heat sources until much later, leaving residents in discomfort. Residents expressed their discomfort and dissatisfaction with the cold temperatures. One resident, wearing a hospital robe and covered with multiple blankets, reported feeling cold since Thanksgiving and stated that requests for a floor heater were ignored. Another resident, also diagnosed with heart failure, mentioned having a cold nose and ears despite being given extra blankets. A third resident, wearing a winter robe, expressed frustration over the ongoing cold conditions and the lack of effective solutions. The fourth resident, who had multiple diagnoses including heart failure and cirrhosis, reported closing a window to prevent cold air from entering and using an oxygen compressor for warmth. Interviews with staff revealed that the issue was known to the Director of Nursing and the Administrator, who acknowledged the need for room temperatures to be between 71 and 81 degrees Fahrenheit. The facility's policy required maintaining a comfortable temperature and ensuring the building was in good repair. However, the maintenance department failed to order floor heaters promptly, and the facility did not provide adequate alternative heating solutions, leading to prolonged discomfort for the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Two dietary staff members were found with uncovered facial hair, which is against the facility's policy and the FDA Food Code 2022, which requires hair restraints to prevent contamination of food and clean equipment. The Dietary Supervisor confirmed the lack of beard guards and acknowledged the oversight. Additionally, the juice machine in the kitchen was found to be unclean, with sticky residue and dust accumulation, contrary to the facility's policy that mandates daily cleaning and maintenance. The Dietary Supervisor admitted the machine was not cleaned as required, highlighting a lapse in adherence to sanitation protocols. Furthermore, several kitchen utensils were improperly stored while still wet, which could foster microbial growth, violating both the facility's policy and FDA guidelines that require air-drying before storage. The facility also failed to ensure the use of pasteurized eggs, as raw shelled eggs were found in the refrigerator and served to residents, including those who consumed over-easy eggs with running yolks. This practice poses a risk of foodborne illness, especially in a vulnerable elderly population. The Dietary Supervisor was unaware of the unpasteurized eggs being delivered and acknowledged the error. Moreover, a dietary aide demonstrated a lack of knowledge in the correct manual dishwashing process, with expired food handler certification and failure to attend relevant in-service training, further indicating gaps in staff training and compliance with established procedures.
Inconsistent Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substance medications for four residents, leading to discrepancies between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR). Resident 33, diagnosed with chronic pain syndrome, had inconsistencies in the documentation of hydrocodone-acetaminophen administration on specific dates, with doses recorded in the CDR but not in the MAR, and vice versa. Similarly, Resident 51, with primary osteoarthritis and chronic pain, had hydrocodone-acetaminophen doses documented in the MAR but missing from the CDR, and vice versa, on various dates. Resident 37, suffering from peripheral vascular disease and abnormal posture, also had discrepancies in the documentation of hydrocodone-acetaminophen doses between the CDR and MAR over several months. Additionally, Resident 73, with primary osteoarthritis of the hip and a malignant neoplasm of the bladder, had lorazepam doses inconsistently recorded between the CDR and MAR across multiple months. During an interview, the Director of Nursing acknowledged the importance of consistent documentation for accountability and proper medication administration timing, as outlined in the facility's policy on controlled medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 17.95% during a medication pass observation. This deficiency involved four residents and included seven medication errors out of 39 opportunities. The errors were observed during the administration of medications by licensed nurses, who did not adhere to prescribed medication schedules and dosages. Resident 3, diagnosed with gastro-esophageal reflux disease and glaucoma, received medications incorrectly. The nurse administered omeprazole later than the prescribed time and failed to instill eye drops correctly. Additionally, the nurse administered a lower dose of vitamin D3 than ordered. Resident 38, with atherosclerosis and peripheral vascular disease, received cilostazol within a meal timeframe, contrary to the order to administer it 30 minutes before or two hours after a meal. Resident 55, diagnosed with cerebral infarction, was given enteric-coated aspirin in a crushed form, which was against the order for chewable aspirin. Resident 67, with kidney atrophy and hydronephrosis, did not receive omeprazole before a meal as prescribed and missed a dose of phenazopyridine due to its unavailability. These errors were confirmed through interviews with the nurses involved and the Director of Nursing, who acknowledged the deviations from prescribed medication administration times and methods.
Failure to Follow Prescribed Dietary Menus
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents on therapeutic diets during lunch meals on 10/21/23 and 10/22/23. On 10/21/23, two residents on a consistent or controlled carbohydrate (CCHO) diet received a full slice of garlic bread instead of the prescribed half slice. Another resident on a dysphagia mechanical (DM) texture diet with thin liquids was served pudding instead of the prescribed ice cream. Additionally, a resident on a finger food (FF) diet received spaghetti instead of the specified bowtie or twister pasta and did not receive a dessert. On 10/22/23, three residents on a DM texture diet were served regular rice and beans instead of the prescribed puree version, and puree apple bread pudding instead of soaked chopped bread pudding. Two residents on a renal and CCHO diet received white rice and regular dessert instead of brown rice and diet dessert. Furthermore, two residents on an FF diet were served pork cut in slices, penne pasta, and diced pear dessert instead of the prescribed bite-sized pork, diced potato with margarine, and apple bread pudding cut in four pieces. These discrepancies were confirmed by the Dietary Supervisor and Registered Dietitian, who acknowledged the failure to follow the menu, potentially compromising the medical and nutritional status of the affected residents.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of five residents during meal service, as observed during a lunch meal distribution. The meal tickets, which included residents' diets, allergies, and specific food preferences, were not followed. For instance, a resident on a regular diet did not receive cottage cheese, while another on a sodium-restricted diet did not receive a side salad with blue cheese dressing. Additionally, a resident on a mechanical soft texture diet did not receive several items, including cottage cheese and chicken noodle soup, and a resident on a dysphagia mechanical texture diet did not receive ice cream. Another resident on a no added salt fortified diet also did not receive cottage cheese. Interviews with the Dietary Supervisor and Registered Dietitian confirmed these findings, acknowledging that the kitchen staff failed to provide the food items as indicated on the meal tickets. The facility's policy on food preferences, dated 2023, stated that residents' food preferences should be adhered to, and the Dietary Supervisor's job description included assessing resident food preferences and checking trays for accuracy before delivery. These deficiencies had the potential to result in meal dissatisfaction and decreased meal intake, which could further compromise the residents' medical and nutritional status.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a medication pass. Licensed Nurse 1 (LN 1) used a blood pressure cuff and stethoscope on a resident in a room with Enhanced Barrier Precautions and did not sanitize the equipment before using it on another resident. LN 2 also failed to change gloves after resident care before sanitizing medical equipment. The Director of Nursing confirmed that equipment should be sanitized between uses and gloves should be changed, as per facility policy. Nail care was neglected for several residents, including those with dementia, muscle weakness, and hemiplegia. Observations revealed long, jagged fingernails with black substances underneath, which residents expressed a desire to have trimmed. The Director of Nursing stated that nail care should be provided weekly, and untrimmed nails could pose an infection risk. The facility's policy indicated that residents unable to perform daily activities independently should receive assistance with grooming and hygiene. Certified Nurse Assistant 5 (CNA 5) did not adhere to neutropenic precautions for a resident with multiple myeloma, failing to wear a gown and mask upon entering the resident's room. The Infection Preventionist confirmed that all staff and visitors should wear protective equipment to prevent infection. The facility lacked a specific policy for neutropenic precautions, relying instead on general isolation guidelines.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 10 resident rooms met the required space standards, with rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 measuring 228.55 square feet for three residents, equating to 76.2 square feet per resident, and room 14 measuring 159.38 square feet for two residents, equating to 79.7 square feet per resident. This deficiency was identified through observation, interviews, and record reviews, confirming that the rooms did not meet the minimum requirement of 80 square feet per resident. Despite the space being adequate for storing assistive devices and facilitating care, the Administrator acknowledged the shortfall in space per resident. Interviews with residents indicated that they felt the space was adequate for their care needs. The Department recommended the continuation of a waiver for these rooms.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care. Resident 18, who was admitted with a compression fracture of the vertebra, had an order for tramadol hydrochloride, a narcotic pain medication, which was not coded in her MDS admission assessment. This oversight was confirmed during a review with the Director of Nursing (DON), who acknowledged the omission of the opioid medication order in the MDS assessment. Similarly, Resident 48, admitted with an intertrochanteric left femur fracture, had pressure ulcers on the left heel and coccyx that were not accurately coded in her MDS admission assessment. The MDS coordinator (MDSC) was unaware of these pressure ulcers and confirmed the omission during a review of the resident's records. The DON expressed that the expectation was for the nurse responsible for the assessments to complete them accurately to ensure appropriate care and interventions for the residents.
Failure to Update Anticoagulant Care Plan
Penalty
Summary
The facility failed to revise and update the care plan for a resident in a timely manner, specifically concerning the resident's anticoagulant medication. The resident, who was admitted in November 2022 with a diagnosis of hemiplegia, had an anticoagulant care plan dated March 2024. This care plan indicated the resident was receiving rivaroxaban. However, a physician's order showed that rivaroxaban was discontinued and replaced with apixaban on September 9, 2024. During an interview and record review, the Assistant Director of Nursing confirmed that the care plan had not been updated to reflect the change in medication. The facility's policy requires care plans to be reviewed and revised at least quarterly or as soon as a new order is received. The failure to update the care plan decreased the facility's ability to provide resident-centered care and evaluate its effectiveness.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards for two residents. Resident 19, who was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), was observed not using her prescribed continuous oxygen therapy. Despite the physician's order for continuous oxygen via nasal cannula at two liters per minute, Resident 19 only used oxygen at night with her CPAP machine. This inconsistency was confirmed by both the Licensed Nurse and the Infection Preventionist, who noted that the resident was not on oxygen during their observations. The Director of Nursing acknowledged that the nursing staff should have followed the physician's orders and revised them if necessary. Resident 40, also diagnosed with COPD, missed scheduled nebulizer treatments on two occasions, as documented in the medication administration record (MAR). The resident reported experiencing shortness of breath and distress due to the missed treatments. The MAR lacked documentation for the administration of ipratropium bromide inhalation on the specified dates, which was confirmed by the Licensed Nurse. The Director of Nursing and the Director of Staff Development emphasized the importance of accurate and timely documentation, stating that if it was not documented, it was not done. The facility's policy requires compliance with professional standards and proper documentation of care provided.
Failure to Adhere to Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for a resident with stage four chronic kidney disease. The resident, admitted in January 2017, had a physician's order for fluid restriction of 1000 milliliters per day, divided into 700 ml for dietary and 300 ml for nursing. Despite this order, three water pitchers were observed on the resident's bedside table, indicating a failure to adhere to the fluid restriction. This oversight was confirmed by a licensed nurse during an observation and interview. Further review of the resident's records and input/output logs by the Assistant Director of Nursing (ADON) confirmed the fluid restriction order due to the resident's dependence on dialysis, which was scheduled three times a week. The ADON stated that it was expected for nurses to follow the physician's orders to prevent complications such as fluid overload. The facility's policy on fluid restriction, reviewed in 2024, also indicated that residents with such orders should not have water pitchers placed in their rooms, highlighting a clear deviation from established protocols.
Inadequate Monitoring of Resident's Behaviors on Quetiapine
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident prescribed quetiapine for dementia with agitation and combativeness. The resident was admitted with a diagnosis of dementia with behavioral disturbance and was prescribed quetiapine 25 mg at bedtime. The facility's Medication Administration Record (MAR) required behavior monitoring for agitation and combativeness every shift, but the night shift only had yes or no options to indicate whether behaviors occurred, lacking a section to quantify the behaviors. Interviews with Licensed Nurse 4 and the Director of Nursing revealed that the night shift's yes or no options were ineffective for quantifying behaviors, which was necessary to assess the medication's effectiveness and plan for gradual dose reduction (GDR). The facility's policy on antipsychotic medication use required staff to observe, document, and report pertinent information regarding the effectiveness of interventions, including antipsychotic medications, to the attending physician. The lack of quantification during the night shift hindered the ability to make informed decisions about the resident's medication management.
Failure to Label Medications with Open Dates
Penalty
Summary
The facility failed to ensure that two medications in a medication cart were properly labeled with open dates, which is a requirement for maintaining medication safety. During an observation and interview, a Licensed Nurse confirmed that two respiratory treatment medications were found unsealed and without open dates in a medication cart. Specifically, an opened and undated foil pouch of budesonide nebulization suspension and a box with an Advair Diskus inhaler were identified. The Licensed Nurse acknowledged that nursing staff were expected to write open dates on pouches containing respiratory medications and that the dates on the medication and box were confusing. The Director of Nursing stated that the expectation was for nursing staff to label medications with open dates to ensure proper tracking and disposal of medications. The facility's policy on medication labeling indicated that medications should be labeled appropriately, following the manufacturer's expiration date for inhalers. The failure to label these medications with open dates increased the potential for administering expired medications to residents, as there was no way to determine when the medications should be discarded.
Failure to Assist Visually Impaired Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance to a resident with impaired vision, identified as Resident 48, during meal times. Resident 48, who was admitted with a diagnosis of dysphagia and significant visual impairment, was observed not eating during lunch because she could not see her food. Despite having an order for feeding assistance and a care plan indicating the need for help due to her visual deficits, staff did not assist her during meals. This lack of assistance was confirmed through interviews with Resident 48, who reported that she was not helped during meals, and with the Director of Rehabilitation, who acknowledged the resident's need for assistance. Further review of Resident 48's records, including her Baseline Care Plan and Minimum Data Set, confirmed her impaired vision and the requirement for feeding assistance. The Director of Nursing also acknowledged that Resident 48 should always be assisted when eating to ensure she receives proper nutrition. The facility's policy on meal assistance, which mandates assistance for residents who cannot feed themselves, was not adhered to in this case, leading to a failure in meeting the resident's nutritional needs.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when an incident occurred where one resident physically assaulted another. Resident 1, who has a history of aggressive behavior and severe cognitive decline due to paranoid schizophrenia and bipolar disorder, was observed punching Resident 2. This incident was witnessed by a Certified Nurse Assistant (CNA 2) who reported seeing Resident 1 punch Resident 2 in the stomach. The altercation was confirmed by the Director of Nursing and the Administrator during interviews. Resident 1's care plan indicated a history of aggressive and combative behavior, with interventions such as providing distractions to calm the resident. Despite these measures, the incident occurred, suggesting a failure in effectively managing Resident 1's behavior. Resident 2, who has mild cognitive decline and a history of verbal aggression, may have triggered Resident 1's reaction. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse, yet this incident highlights a lapse in ensuring this protection.
Failure to Ensure Dignity and Timely Assistance for Residents
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident 1 had to wait three hours on a bedpan for assistance. Despite pressing the call light multiple times, the resident was not attended to promptly. The resident's daughter had to be called for help, and the resident expressed feelings of neglect and being less important. Interviews with CNAs and the Director of Nursing confirmed the incident and highlighted a failure to meet the facility's expectation of answering call lights within five minutes. Resident 2's call light was not accessible when she was in her wheelchair, making it difficult for her to request assistance. During observations, the call light in Resident 2 and another resident's room was on for an extended period without being answered. Multiple staff members were observed walking past the call light without responding. Resident 2 expressed frustration about not being able to find her call light and not receiving timely assistance to go to the bathroom. The facility's policies on answering call lights, activities of daily living, and promoting dignity were not followed, leading to these deficiencies. The failure to respond to call lights and provide timely assistance compromised the residents' dignity and ability to receive necessary care.
Resident Elopement Due to Non-Functional Monitoring Systems
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who eloped from the facility, resulting in a fall and subsequent injuries. The resident, who had a history of cognitive impairment and was at risk for elopement, was able to leave the facility unnoticed due to non-functional or semi-functional wanderer monitoring systems on three out of four main entrance/exit doors. The resident's elopement care plan and physician's order for a wander guard were not followed, contributing to the incident. The resident had been admitted with multiple diagnoses, including traumatic subdural hemorrhage, cerebral infarction, and cognitive communication deficit, and was assessed as being at risk for elopement. Despite this, the facility's staff failed to adequately monitor the resident's whereabouts and ensure the proper functioning of the wander guard and door alarms. Interviews with staff revealed that the door alarms were either not functioning or had low sound levels, making it difficult for staff to hear and respond to potential elopements. Additionally, the facility's policy and procedures for monitoring and maintaining the wanderer monitoring system were not adhered to. Staff were unaware of the resident's wander guard status, and there was a lack of communication and responsibility regarding the checking and maintenance of the wander guard and door alarms. This lack of adherence to established protocols and failure to ensure the safety of a resident at risk for elopement resulted in the resident's unauthorized departure and subsequent injuries.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 104 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.2 mi | ★★★★★ | 11 | 0 |
| Gold Country Health Center | 2.5 mi | ★★★★★ | 20 | 0 |
| Rock Creek Care Center | 19.3 mi | ★★★★★ | 9 | 0 |
| Auburn Ravine Healthcare Center | 19.8 mi | ★★★★★ | 19 | 0 |
| Folsom Care Center | 20.7 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.