Above 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 Western Slope Health Center during CMS and state inspections, most recent first.
Food storage and sanitation practices were not maintained in the kitchen. Clean sheet pan shelves had food debris, a container was stored wet in the clean storage area, two cups of yogurt were left uncovered in the refrigerator, and the microwave used for residents' food had dried food splashes. The DS confirmed each issue during observation, and the RD acknowledged the associated foodborne illness risk.
Failure to monitor psychotropic medication use and document non-pharmacological interventions. Two residents had psychotropic medication orders, including quetiapine, lorazepam, and olanzapine, but the MR did not show target behavior monitoring, side effect monitoring, or documented non-pharmacological interventions. An LPN/LN and the DON confirmed the missing documentation and that these monitoring steps were expected.
Controlled medication records were not accurately reconciled for two residents when oxycodone and tramadol were signed out in the CDR but not documented on the MAR as administered. In another observation, an LPN gave two oxycodone tablets to a resident but did not sign them out in the CDR at the time of administration. The DON confirmed staff were expected to document controlled medications in both the CDR and MAR when administered.
Infection control practices were not followed for respiratory equipment, food transport, catheter care, and EBP. A resident’s CPAP and nebulizer masks were left out without antimicrobial bags, another resident’s oxygen tubing was on the floor, uncovered salad was transported through the hall on meal trays, a foley drainage bag touched the floor, and wound care for a resident with a chronic sacral wound was performed without the required gown use under EBP.
Failure to provide nail care and hand hygiene for a resident who required maximal assistance with personal hygiene. The resident had long fingernails with brownish black sediment underneath them during repeated observations, and stated that no one offered nail care or asked to clean the nails. The DSD stated CNA was expected to provide the nail care, and the care plan had no person-centered ADL plan related to nail care.
A resident with a history of atrial fibrillation and atrial flutter did not receive prescribed Amiodarone for five days because the medication was not available, and the physician was not notified of the missed doses. The DON confirmed that staff did not follow physician orders or facility policy regarding medication administration and notification.
The facility failed to store potentially hazardous foods properly, leaving items like unpasteurized eggs and meats unrefrigerated for over two hours. Expired banana pudding was found in the refrigerator, and salad dressings were stored without labels or dates, violating the facility's food safety policies.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident received anti-anxiety medication without documented non-pharmacological interventions, while another did not receive ordered bladder scans due to a missing scanner. The lack of documentation and communication with the physician were confirmed by staff.
The facility failed to properly date and store opened medications for two residents, risking the use of medications with reduced potency. An opened Ozempic pen was found without a date label, and another was without a cap, increasing contamination risk. A nurse highlighted the importance of proper labeling and storage, while the DON noted the need for staff to verify expiration dates and ensure correct storage.
The facility failed to follow infection prevention guidelines by not labeling personal wash basins and male urinals, increasing infection risk. Observations showed unlabeled basins shared by residents, with staff citing HIPAA misunderstandings. Male urinals were inconsistently labeled, risking urinary tract infections. The facility's policy required labeling and regular changes, but these were not consistently followed.
The facility failed to meet minimum staffing requirements, with deficiencies in both overall direct care services hours and CNA hours on multiple days. Interviews with staff and residents revealed that these shortages led to significant delays in answering call lights, particularly during night shifts. The reliance on registry staff contributed to inconsistent care, impacting residents' routines and satisfaction.
The facility failed to properly dispose of garbage, with a trash bin observed overflowing and not fully closed, potentially attracting pests. This was confirmed by staff, and the facility's policies require tight-fitting lids to prevent such issues.
A facility failed to maintain an effective pest control program, resulting in a fly infestation observed in hallways and a resident's room. Staff, including LNs and the DON, confirmed the presence of flies and noted ineffective control measures. The issue was linked to open doors and garbage, posing infection control concerns. Facility policies on cleanliness and pest control were not effectively implemented.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards during kitchen observations. Food debris were observed on shelves that stored clean and ready-to-use sheet pans, and the Dietary Supervisor confirmed the shelves were dirty. A half-gallon plastic container was also observed stacked wet in the clean and ready-to-use storage area, and the Dietary Supervisor confirmed it was wet and stated containers should be completely dry before storage. In addition, two small containers of yogurt were observed uncovered in the refrigerator, and the Dietary Supervisor confirmed they should have been covered. The interior of the microwave used for residents' food was observed with splashes of dry food, and the Activities Director confirmed it was dirty and needed to be cleaned. The Registered Dietician acknowledged the risk for foodborne illness when food debris were on the shelves, when the container was stored wet, when the yogurt was uncovered, and when the microwave was dirty.
Failure to Monitor Psychotropic Medication Use and Document Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were implemented and that target behaviors and side effects were monitored for two residents receiving psychotropic medications. One resident, admitted with PTSD, had orders for quetiapine at bedtime for paranoid delusions and lorazepam as needed for anxiety/agitation, but the medical record did not show monitoring of target behavior or side effects related to lorazepam, and non-pharmacological interventions were not implemented with the use of quetiapine and lorazepam. During interview and record review, the LN and DON both confirmed that these monitoring and intervention requirements were expected and that they were not documented for this resident. A second resident, admitted with delirium and unspecified dementia with behavioral disturbances, had an order for olanzapine at bedtime for behavioral and psychological symptoms of dementia, including auditory hallucinations. The medical record did not show that non-pharmacological interventions were implemented or documented before administration of olanzapine. During interview and record review, the LN stated he did not see non-pharmacological interventions implemented before the psychotropic medication was used, and the DON confirmed that the resident did not have non-pharmacological interventions implemented or documented. The facility policy on psychotropic medication use stated that non-pharmacological interventions would be considered as applicable and that staff would observe, document, and report effectiveness and side effects of psychotropic medications.
Controlled Medication Documentation and Reconciliation Errors
Penalty
Summary
The facility failed to ensure accurate accountability and documentation of controlled medications for two residents when the Controlled Drug Record (CDR) and Medication Administration Record (MAR) did not match. For one resident, the physician ordered oxycodone HCL 15 mg every 6 hours as needed for moderate to severe pain, and the CDR showed tablets signed out on two occasions, but the MAR did not show the medication was administered on those dates and times. For another resident, the physician ordered tramadol 50 mg every 6 hours as needed for moderate pain, and the CDR showed a tablet signed out, but the MAR did not document administration on that date and time. The DON confirmed the CDRs and MARs were not accurate and that nursing staff were expected to document controlled medications in both records when removed from the cart and administered. During a medication administration observation, an LPN prepared and administered two oxycodone 5 mg tablets to a resident, but did not document the dose in the CDR at the time of administration. In a later interview and record review, the LPN confirmed she had not signed out the tablets in the CDR when they were given and acknowledged documentation was required in both areas immediately. The DON stated staff were expected to document in both the CDR and MAR any time a controlled medication was removed from the cart and administered, and the facility policy on controlled substances stated controlled substance inventory is reconciled using medication administration records and declining inventory records.
Infection Control Failures With Respiratory Equipment, Food Transport, Foley Care, and EBP
Penalty
Summary
The facility failed to implement infection prevention and control practices for respiratory equipment used by two residents. One resident with COPD and OSA had a CPAP order and had recently received nebulizer treatment, but during observation the resident’s nebulizer mask was sitting on the bedside table and the CPAP mask was hanging on the bedside rail, both without storage in an antimicrobial bag. Another resident with hypoxemia, OSA, shortness of breath, and dependence on supplemental oxygen had a nebulizer mask left on top of the nebulizer machine without a bag, and the oxygen tubing was dragging on the floor from the bed, under the roommate’s bed, and into the restroom, with the concentrator stored in the restroom and the tubing touching the restroom floor. The infection preventionist stated the masks should be stored in an antimicrobial bag when not in use and that oxygen tubing should not touch the floor. The facility also failed to protect uncovered food during transport. During observation, meal trays with uncovered salad were moved from the dining cart through the hallway into resident rooms while the cart remained parked in the middle of the hall. The CNA confirmed the trays were transported through the hall with uncovered salad. The RD stated the cart should have been parked outside the resident rooms to avoid contamination of uncovered food during transport. The facility further failed to keep a resident’s foley catheter drainage bag off the floor and failed to follow Enhanced Barrier Precautions during wound care. A resident with an indwelling foley catheter had the drainage bag hanging from the bottom of the wheelchair and touching the floor, which the CNA confirmed. In another observation, wound care was provided to a resident with a chronic stage 3 sacral pressure ulcer while the resident’s room did not have an EBP sign posted, and the nurses performed hand hygiene and donned gloves but did not wear gowns during direct wound care involving the sacral area and surrounding linens. The infection prevention nurse confirmed the EBP order and care plan were active and that EBP precautions were not followed as ordered.
Failure to Provide Nail Care and Hand Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with nail care and hand hygiene for one resident who was unable to perform these activities independently. Resident 11 was admitted with acute and chronic respiratory failure with hypoxia and morbid obesity, and the MDS dated 1/22/26 indicated the resident required maximal assistance for personal hygiene. During observations on 3/3/26, 3/4/26, and 3/5/26, the resident’s fingernails were observed to be long with brownish black sediment underneath each fingernail. When asked on 3/3/26 whether nail care had been offered, the resident stated, “No. They were too busy.” On 3/4/26, the resident stated, “No one asked me and no one offered to clean my nails.” During a concurrent observation and interview on 3/5/26, the Director of Staff Development stated the expectation was for the CNA to do the nail care. The DSD and nurse surveyor then observed the resident’s hand and confirmed the long fingernails with brownish black sediment underneath each nail. The DSD asked if the fingernails could be cleaned, and the resident agreed. A review of the resident’s care plan initiated on 10/9/25 showed no evidence of a person-centered care plan related to ADLs, including nail care. The facility policy titled Activities of Daily Living (ADLs), Supporting, revised 10/2025, stated residents will be provided ADL care to ensure their ADLs are met and that care and services will be provided for residents who are unable to carry out ADL independently.
Failure to Administer Prescribed Antiarrhythmic Medication and Notify Physician
Penalty
Summary
Resident 1, who was admitted with multiple diagnoses including paroxysmal atrial fibrillation and unspecified atrial flutter, did not receive the prescribed antiarrhythmic medication, Amiodarone, for five consecutive days. The physician's order specified that the medication should be administered daily, but a review of the Medication Administration Record (MAR) confirmed that the medication was not given on the specified dates. The Director of Nursing (DON) verified that the medication was not available at the facility during this period and that the physician was not notified about the missed doses. Facility policies required medications to be administered according to prescriber orders and for the physician to be notified in the event of missed medications. Despite these policies, the nursing staff did not follow the physician's order for medication administration and failed to notify the physician when the medication was not available and not given. The DON acknowledged that the resident did not receive the prescribed medication for five days and that the physician should have been informed.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage, which could potentially lead to foodborne illness among residents. During an inspection, it was observed that potentially hazardous foods such as unpasteurized eggs, cheese, half and half, turkey, and ham were left unattended on the floor and shelving outside of the kitchen refrigerator for more than two hours. The kitchen staff, including the cook and dietary manager, confirmed that these items should have been refrigerated within two hours to prevent spoilage. Additionally, expired banana pudding was found in the kitchen refrigerator, and the dietary manager acknowledged that it should have been discarded according to the facility's policy, which allows a maximum refrigeration time of three days for prepared desserts. Furthermore, twelve individual containers of salad dressing were found unlabeled and undated in the kitchen refrigerator, contrary to the facility's policy that requires all prepared foods to be covered, labeled, and dated. The dietary staff confirmed the oversight and acknowledged the importance of proper labeling to ensure food safety. These deficiencies in food storage and labeling practices were identified through observations, interviews with kitchen staff, and a review of the facility's policies, highlighting a lapse in following established food safety protocols.
Failure to Follow Physician Orders for Medication and Bladder Scans
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident 94, who was admitted with diagnoses including nerve pain and generalized anxiety, the facility did not follow the physician's order to attempt non-pharmacological interventions before administering Lorazepam, an anti-anxiety medication. The medication was administered multiple times without documented evidence of non-pharmacological approaches being attempted, as confirmed by both a Licensed Nurse and the Director of Nursing. This oversight was noted in the Medication Administration Record (MAR), which lacked documentation of any non-pharmacological interventions prior to medication administration. For Resident 6, who was admitted with urinary issues, the facility failed to perform and document bladder scans as ordered by the physician. The After Visit Summary specified that bladder scans should be conducted three times daily after each void, but no results were recorded in the MAR for several consecutive days. Interviews with Resident 6 and a Licensed Nurse revealed that the bladder scanner was reportedly lost, and the scans were not performed. The Director of Nursing acknowledged the lack of documentation and the failure to notify the physician about the missed scans, which were deemed important by the resident's urologist.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that opened medications were dated and properly stored for two residents, which could lead to the use of medications with unsafe or reduced potency. During an observation in the medication room, an opened Ozempic injection pen for one resident was found stored inside a resealable bag without a written opened date on the label. Another open Ozempic injection pen for a second resident was found in the same bag without a pen cap to cover the pen window where the needle was attached. Licensed Nurse 5 emphasized the importance of dating and labeling Ozempic when opened to avoid using expired medication, which could be less effective. The nurse also noted that storing Ozempic without a cap could increase the risk of contamination, potentially leading to adverse effects for residents. The Director of Nursing stated that staff should verify expiration dates on Ozempic injection pens, record the date when a pen was first opened, and ensure proper storage of these medications. The manufacturer's instructions for Ozempic indicate that the pen should be stored at room temperature for 56 days and disposed of after this period, even if it still contains medication, and that the pen cap should be kept on when not in use.
Infection Control Deficiency Due to Unlabeled Basins and Urinals
Penalty
Summary
The facility failed to adhere to infection prevention guidelines by not labeling personal wash basins and male urinals, which increased the risk of infection among residents. Observations revealed that personal wash basins shared by residents were unlabeled, contrary to the facility's policy that required labeling with the resident's name. Certified Occupational Therapy Assistant 1 confirmed the lack of labeling and mentioned a misunderstanding regarding HIPAA regulations as a reason for not labeling the basins. The Director of Staff Development expected CNAs to label basins with residents' names, not room numbers, due to frequent room changes. Additionally, male urinals were inconsistently labeled, with some containing only the resident's last name or room number, while others were completely unlabeled. This inconsistency was confirmed by License Nurse 6, who acknowledged the risk of urinary tract infections due to improper urinal management. The Director of Nursing expected urinals to be changed every two weeks and labeled with the resident's name and the date of the last change. The facility's policy on infection prevention and control emphasized the importance of measures to prevent complications and the need for staff education on proper techniques. However, the observations and interviews indicated a lack of adherence to these guidelines, as evidenced by the unlabeled basins and urinals, which could potentially compromise resident safety and increase the risk of infection.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to meet the minimum staffing requirements, specifically the 3.5 direct care services hours per day (DHPPD) and the 2.4 Certified Nursing Assistant (CNA) DHPPD, on multiple days during the audit period. The facility did not meet the 3.5 DHPPD on three out of 23 days and failed to meet the 2.4 CNA DHPPD on 21 out of 23 days. This deficiency was identified through a review of the facility's NHPPD Scheduled Daily Staffing Overview forms. Interviews with staff and residents revealed that the lack of adequate staffing led to delays in answering call lights, with some residents experiencing waits of up to an hour, particularly during night shifts. The use of registry staff was noted as a contributing factor to the inconsistency in care and delays in response times. Interviews with CNAs and residents highlighted the impact of staffing shortages on the quality of care. CNAs reported frequent call-offs and reliance on registry staff, which affected their ability to provide timely care. Residents expressed dissatisfaction with the delays in call light responses, noting that the inconsistency in staffing led to challenges in receiving care according to their routines. The facility's policy on answering call lights emphasized prompt responses, yet the staffing deficiencies hindered adherence to this policy. The All Facilities Letters (AFL) 19-16 outlined the minimum staffing requirements, and the facility's failure to meet these standards resulted in non-compliance with regulatory expectations.
Improper Garbage Disposal Leading to Pest Attraction
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. A trash bin was found with garbage bags rising out of the top, preventing the lid from being fully closed. This observation was made in the garbage disposal area outside the facility, where six trash bins and one biohazard bin were located. The improper closure of the trash bin was confirmed by both the Housekeeping Staff and the Maintenance Director during interviews. The Housekeeping Staff noted an increase in flies, potentially linked to the garbage situation. The Administrator acknowledged the issue upon being shown a picture of the trash bin and contacted the Maintenance Director. The facility's policies and procedures, as well as the US FDA 2022 Food Code, require that garbage receptacles have tight-fitting lids to prevent pest attraction. The facility's policy also mandates that garbage and refuse containers be kept covered when not in use and that garbage containing food waste be stored in a manner that prevents pests. The failure to adhere to these guidelines was identified as a deficiency during the survey.
Pest Control Deficiency Due to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in the hallways and in a resident's room. During an observation and interview, flies were seen moving around the room, on the resident's blanket, and on the curtains. The resident mentioned that everyone, including themselves, had complained about the flies. Licensed nurses confirmed the presence of flies and noted that the lights installed to control the infestation were ineffective. One nurse mentioned that the issue should be logged in the maintenance records, highlighting it as both an infection control and dignity issue. Housekeeping staff were observed using a fly swatter and suggested that the flies might be coming from the garbage outside. The Maintenance Director acknowledged the problem, attributing it to high traffic and open doors. The Director of Nursing recognized the flies as a significant infection control issue, and the Administrator expressed concern about the risk of spreading infections and diseases. The facility's policies on physical environment and pest control were reviewed, indicating that the facility should be clean, safe, and free of pests, but these policies were not effectively implemented.
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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) |
|---|---|---|---|---|
| The Pines At Placerville Healthcare Center | 0.2 mi | ★★★★★ | 14 | 0 |
| Gold Country Health Center | 2.4 mi | ★★★★★ | 20 | 0 |
| Rock Creek Care Center | 19.4 mi | ★★★★★ | 9 | 0 |
| Auburn Ravine Healthcare Center | 20 mi | ★★★★★ | 19 | 0 |
| Folsom Care Center | 20.7 mi | ★★★★★ | 24 | 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 July 2026) and official state health department websites.