The Pines at Placerville Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice when the care plan for use of antibiotics (medications used to treat infections) was not followed for Resident 1. This failure had the potential for Resident 1 to experience adverse drug reaction from the antibiotic without the knowledge of staff. A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including depression (persistent feeling of sadness and loss of interest) and irritable bowel syndrome (chronic condition affecting the digestive system). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to not employ an individual who has been found guilty of abuse or mistreatment by a court of law for one out of three sampled employees (Employee1), when Employee 1's background check indicated he was convicted of battery in 2019 and the facility was made aware of another violent conviction in 2021. This failure has the potential to risk the safety of all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices for a census of 89 when:The tip of Resident 6's enteral feeding tube (a medical device used to deliver nutrition, fluids, and medications directly to the stomach) was observed hanging from the IV pole without a protective cap;Staff did not follow infection prevention protocols when entering the resident's room; andStaff touched the lunches of Resident 52 and Resident 17 with their bare hands. These failures placed residents at risk for spread of infections, disease outbreaks, increased hospitalization and serious health complications for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for two of 21 sampled residents (Resident 25 and Resident 54) when:1. Resident 25's breakfast tray left within reach without staff present; and2. Resident 54's call light was not within reach. These deficiencies had the potential to place Resident 25 at risk for aspiration and resulted in delayed staff response for Resident 54's needs.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that the physical environment was maintained in a clean, safe, and homelike condition. One of five corridors containing15 resident rooms, a hole was observed in the ceiling. The ceiling around the hole showed visible water damage including staining and deterioration consistent with a leak from a pipe above the celling. This failure to maintain the building structure in good repair has the potential to lead to mold growth, further structural damage and safety hazards for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for a census of 89 when:1. Staff did not assess for and treat Resident 12's shortness of breath;2. Staff administered the wrong dose of morphine sulfate for Resident 60; and3. Staff did not accurately complete the weekly summary for Resident 92. These findings had the potential to delay care for Resident 12 and Resident 92, cause inadequate pain control for Resident 60, lead to adverse reactions from medications for Resident 60, and compromise resident safety for Resident 92.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate did not exceed 5% for a census of 89 when: Resident 95's pantoprazole (a medication used to treat heartburn) was crushed;Resident 95's liquid fluconazole (a medication used to treat fungal diseases) was not shaken prior to administration; andResident 60 did not receive the ordered dose of her liquid morphine. These failures resulted in a medication error rate of 10.34% with three medication errors observed out of 29 medication administration opportunities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy for a census of 89 when expired medications were not disposed of. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and record review, 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 (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three residents occupancy or 76.2 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 27 residents residing in these rooms for a census of 89 residents.

Inspectors wroteBased on the interview and record review, the facility failed to protect one of three sampled residents (Resident 2) to be free from physical abuse when Resident 1 swung his arms several times at Resident 2, contacting Resident 2's upper body. This failure resulted in Resident 2 with pain from being hit. During a review of Resident 1's admission record (AR), dated 9/23/25 (print date), the AR indicated that Resident 1 was admitted to the facility in mid-2025 with diagnoses which included dementia (memory loss that gets worse over time), anxiety (fear, worry), depression (a serious mood disorder causing prolonged feelings of sadness or loss of interest that interfere with daily life), restlessness and agitation. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/21/25, the MDS indicated Resident 1 had severely impaired cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medical record for one of four sampled residents (Resident 1's) was accurate, consistent and timely when the clinical assessments were contradictory and inconsistent among healthcare professionals. This failure had the potential to lead to incorrect clinical decisions, delays in care and an increased risk of misdiagnosis and inappropriate treatment for Resident 1.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Medical Director provided oversight and coordination of care for one of four sampled residents (Resident 1) when the MD did not step in and resolve differing clinical opinions about whether Resident 1 was ready for discharge. This failure placed the resident at risk for being discharged prematurely or kept unnecessarily in Skilled Nursing level of care and raised concerns for care coordination, accountability and patient safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain room temperature at a comfortable and safe level for four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) out of a census of 88, when: 1. Resident 1 ' s, Resident 2 ' s, Resident 3 ' s, and Resident 4 ' s room temperatures were below 71 degrees Fahrenheit (°F; a unit of measure); and 2. The maintenance department did not provide alternative heat sources after the heating, ventilation, and air conditioning (HVAC) system broke. These failures increased the residents ' potential for discomfort and loss of body heat.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety, when: 1. Two dietary staff had facial hair were not covered; 2. Juice machine was not clean; 3. Several various sizes of kitchen utensils were stacked wet stored at the clean and ready-to-use storage areas; 4. The raw shelled eggs were not pasteurized in the walk-in refrigerator; and 5. One dietary aide was not able to demonstrate and verbalize the correct process of manual dishwashing by using three-compartment sink. These failures had the potential to cause food borne illness in a medically vulnerable 88 out of 91 residents who consumed food in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled substance medications (medications that the use and possession of are controlled by the federal government) for four residents (Resident 33, Resident 37, Resident 51, and Resident 73) of a census of 91 were accurately accounted on the Medication Administration Record (MAR) and Controlled Drug Record (CDR). This failure decreased the facility's potential to ensure accurate accountability for residents' controlled medications and prevent its misuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%) for four residents (Resident 3, Resident 38, Resident 55, and Resident 67) of a census of 91, when seven medication errors out of 39 opportunities were observed during medication pass. This failure resulted in medication error rate of 17.95% for the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet during the lunch meals on 10/21/23 and 10/22/23 when: A. Dining observation on 10/21/24: 1. Two residents (Resident 18 and 58) with consistent or controlled carbohydrate (CCHO) diet (diet for people need to control their blood sugar or to manage diabetes) received one slice of garlic bread instead of half (1/2) slice; 2. Resident 35 with dysphagia mechanical (DM) texture diet (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) with thin liquids (regular liquid consistency) received pudding instead of ice-cream as dessert, and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the food preferences (food items under the standing order) on the meal tickets (tickets including resident's diet, date, allergies, specific food and beverage items, dislikes, likes) for five residents (Resident 1, 2, 4, 8, and 81) out of 88 residents who received meals from the facility's kitchen. These deficient practices had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for a census of 91 when: 1. Nursing staff did not sanitize and disinfect medical equipment between resident use and did not change gloves after resident care and when cleaning equipment; 2. Nail care was not provided for Resident 8, Resident 14, Resident 38, Resident 39, and Resident 73; and 3. Certified Nurse Assistant 5 (CNA 5) did not wear the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) upon entering Resident 27's room who was on neutropenic precautions (a set of action to take to prevent infection if there's a low count of white blood cell in the blood that helps fight infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 10 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 14, 15, and 16) met the required 80 square feet (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three residents occupancy or 76.2 sq. ft. per resident; and room [ROOM NUMBER] was measured as 159.38 sq. ft. for a two residents occupancy or 79.7 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 29 residents residing in these rooms for a census of 91 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS- a federally mandated resident assessment tool) for two of 25 sampled residents (Resident 18 and Resident 48), when: 1. Resident 18's use of narcotic pain medication was not coded in the MDS admission assessment; and 2. Resident 48's pressure ulcers (PUs; localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were not accurately coded in her admission assessment. This failure decreased the facility's potential to provide residents with appropriate care and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise in a timely manner the care plans for one of 25 sampled residents (Resident 30), when: 1. Resident 30's anticoagulant care plan was not revised and updated since 3/23/24; and These failures decreased the facility's potential to provide resident-centered care plans and evaluate its effectiveness. Findings 1. A review of an admission record indicated, Resident 30 was admitted to the facility in November 2022 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). A review of Resident 30's clinical record included the following documents: An anticoagulant (medication that prevent or reduce blood clotting) care plan, dated 3/23/24, indicated Resident 30 was receiving rivaroxaban (blood thinner that treats or prevents blood clots). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services according to professional standards of quality for two of 25 sampled residents (Resident 19 and Resident 40), when: 1. Resident 19's administered oxygen was not consistent with the physician's order; and 2. Resident 40 missed nebulizer (a liquid medication turned into a mist by a machine and inhaled through a mask used to treat lung diseases) treatments on 10/4/24 and 10/15/24. These failures decreased the facility's potential to safely follow the physician's order when providing respiratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 11) received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care and services consistent with professional standards of practice, when Resident 11's order for fluid restriction was not followed as per physician's order. This failure increased Resident 11's risk to develop fluid overload.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor behaviors for quetiapine (a drug that treats mental health disorders) administration to one resident (Resident 35) of a census of 91. This failure had the risk for residents' ineffective medication management and inadequate decision-making for medications' gradual dose reduction (GDR).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two medications in a medication cart were properly labeled with open dates (dates residents start using a product) for a census of 91. This failure increased the facility's potential to administer expired medications to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance was provided to one of 25 sampled residents (Resident 48), when Resident 48 who had impaired vision was not assisted with eating as ordered. This failure decreased the facility's potential to meet Resident 48's nutritional needs.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure one Resident's (of four sampled residents) right to be free from abuse when staff witnessed Resident 1 punch Resident 2. This failure resulted in Resident 1 having experienced physical abuse by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were treated with dignity and respect when: 1. Resident 1 had to wait three hours on a bedpan for assistance; and, 2. Resident 2's call light was not accessible when she was up in her wheelchair. These failures decreased the facility's potential to ensure residents received the care they needed and were treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable accident for one of 90 residents (Resident 1), when: 1. Resident 1 eloped from the facility, fell, sustained injuries, was found by police and transferred to a hospital, 2. Three out of four main entrance/exit doors had a non-functional or semi-functional wanderer monitoring system; and 3. Resident 1's wander guard physician order and elopement care plan were not followed. These failures decreased the facility's potential to maintain residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine medications for one of three sampled residents (Resident 1) when the resident's prescription medications were not refilled in a timely manner. This failure resulted in Resident 1 having withdrawal symptoms including unbearable pain, anxiety, and insomnia.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive resident centered care plan was developed for one of three sampled residents (Resident 1), when Resident 1's at risk for falls care plan did not list safety measures for the resident's gait and balance problem. In addition, Resident 1's risk for altered ADLs (activities for daily living) care plan did not have the resident's specific interventions addressing the needs for assistance with ambulation. This failure had the potential to have contributed to Resident 1's recent fall and placed her at risk for more falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of four sampled residents (Resident 4) when: 1. Resident 4's care plan intervention to prevent Resident 4 from entering other residents ' room was not properly implemented; and, 2. Resident 4's care plan for an allegation of hitting another resident on the private area on 11/27/23 was not developed. These failures placed Resident 4 and other residents in the facility at increased risk for physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurately documented medical records for five residents (Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) of a census of 85, when the residents' bowel and bladder (B&B) continence data was not documented. This failure decreased the facility's potential to assess and monitor the residents' B&B status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents dignity was promoted for one of two sampled residents (Resident 1) when Resident 1 was left for 2 and a half hours in the hospital lobby and then in a locked van at the hospital parking lot unattended. This failure resulted in Resident 1 feeling of being treated like a dirt, not respected and getting sick and nauseated.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff was competent for a census of 82 when, 15 of 24 Certified Nursing Assistants (CNA's) had not received annual competency evaluations. This failure had the potential for residents to receive unsafe care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet resident needs when: 1. Medication was not re-ordered on time to ensure availability for Resident 335. 2. Resident 17 was not appropriately identified before medication administration; 3. An E-Kit (an emergency supply of medication) was accessed without completing required documentation; and 4. Three of four randomly selected controlled drug (medications with a high potential for abuse, misuse and diversion) records did not reconcile with the Medication Administration Record (MAR) for Residents 13, 26, and 54. These failures increased the potential for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility had a 6.45% error rate when 2 medication errors out of 31 opportunities were observed during a medication pass for 2 out of 6 residents (Resident 5 and Resident 335). These failures had the potential for the residents to not receive the full therapeutic effect of their medications when not given in accordance with the prescriber's order and manufacturer's specifications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policies and procedures when: 1. Expired medications were found inside Medication Cart 3, and Station 2 Medication Storage Room refrigerator; 2. Inspection of a medication storage room and two medication carts displayed pharmaceutical products that were not properly labeled with open dates, and 19 loose pills; 3. Medication Carts 1 and 4 were left unlocked and unattended and; 4. Medication was not appropriately labeled to alert staff of a dosage change. The deficient practices had the potential for residents to receive discontinued and expired medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 59) was able to receive a flavorful and nutritious meal when recipes were not followed. This failure has the potential to decrease Resident 59's appetite and could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritious vegetables for a census of 82 when dietary staff did not follow the recipe when cooking carrots and peas. This failure decreased the potential for residents to receive nutrient-based food values and increased their potential for weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was safely stored and prepared when: 1. Opened and unlabeled food was stored in the refrigerator; 2. Dietary staff did not wear hair nets and beard guard while in the kitchen; and 3. The Dietary Service Supervisor (DSS) did not wash hands prior to entering the kitchen. These failures decreased the facility's potential to prepare, store, and provide food under sanitary conditions for a census of 82.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 82 when: 1. Resident 12's bedding was on the floor and numerous flies were on the resident; 2. Two sharps containers were above the fill line; 3. Hand hygiene was not performed prior to entering and exiting resident rooms; 4. Reusable resident equipment was not disinfected between residents; 5. PPE (Personal Protective Equipment, protective clothing donned to protect the wearer from injury or infection) was not changed prior to entering and exiting resident rooms; 6. Clean linen was transported through the soiled linen area; 7. Resident 48's nebulizer tubing and mask were unlabeled; 8. Resident 185's IV (intravenous therapy, tubing that administers medications directly into the vein) dressing was unlabeled; 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest free environment for a census of 82 when flies were presented throughout the facility. This failure decreased the facility to maintain a sanitary, safe, and infectious free environment for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 30 and 67) were able to maintain dignity when: 1. Resident 30's urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) was not covered with a privacy bag; and 2. Resident 67 urinated himself while waiting for the call light for 1 hour. These failures increased the potential to negatively impact the residents' self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to notify one of 24 sampled residents' (Resident 58) emergency contacts when there was a dosage increase in their psychotropic medication (medications that affect a person's mental state). This failure deprived the resident of his emergency contact's involvement in his care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 17) was able to maintain privacy during ADLs (Activities of Daily Living, fundamental skills required to care for oneself) when, there were three missing horizontal window blinds. This failure decreased Resident 17's feeling of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 24 sampled residents (Resident 12, Resident 79 and Resident 9) were provided a comfortable and homelike environment when; 1. Resident 12 had numerous flies on her bed linens, her tray table was dirty, and the drywall of the exterior room was damaged; 2. Resident 79's bathroom had water leaking from bathroom sink and a puddle of water was on the floor and; 3. Resident 9 had 2 flies on his arm while eating lunch. These failures had the potential to negatively impact the residents' comfort and create an environment that was not homelike.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 24 sampled residents' (Resident 54 and Resident 30) care plans were developed and implemented when, 1. Resident 54 was not turned and repositioned every 2 hours and; 2. A care plan was not developed for Resident 30. These failures placed the residents at risk for skin deterioration and developing urinary tract infections (UTI). 1. According to the Resident Face Sheet, Resident 54 was admitted in the summer of 2021 with diagnoses including rheumatoid arthritis (a chronic inflammatory disorder affecting many joints) and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 54's clinical record included the following documents: A MDS (Minimum Data Set, an assessment tool), dated 9/30/22, indicated the resident had severe memory impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for one of 24 sampled residents (Resident 84) when, the resident left AMA (Against Medical Advice) and was not provided with medications, durable medical equipment (DME) and follow up services. This failure had the potential to result in a preventable readmission.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 24 sampled residents (Resident 47 and Resident 54) received adequate assistance with ADLs (Activities of Daily Living, self-care activities) when, showers were not given as scheduled. This failure placed the residents at risk for uncleanliness, body odor and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed nurse had appropriate skills and competencies to provide care for residents based on their identified needs for a census of 82. This failure had the potential to place residents at risk for insufficient care when Licensed Nurse (LN) skills were not demonstrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 76) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: Resident 76 received as-needed (PRN) Ativan® (an anti-anxiety medication) without an adequate indication for use and clinical justification for its continued use beyond 14 days. The failure had the potential for unnecessary medication for the resident, and exposure to unwanted side effects associated with psychotropic medication use that include, but are not limited to: sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure 10 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 9, 14, 15, and 16) met the required 80 square feet (sq. ft.) per resident when rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 were measured as 228.55 sq. ft. for a three resident occupancy or 76.2 sq. ft. per resident; and room [ROOM NUMBER] was measured as 159.38 sq. ft. for a two resident occupancy or 79.7 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of health care and services for 25 residents residing in these rooms for a census of 82 residents.