The Pines at Placerville Healthcare Center

In the surveyor’s words

From the most serious findings on record at The Pines at Placerville Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 5, 2022

  Based on interview and record review, the facility neglected one resident (Resident 1) of two sampled residents when Resident 1 showed signs of [CONDITION(S)] (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death) and staff failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure led to a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS, an assessment tool), dated 7/3/21, indicated Resident 1 had no memory problems. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Oct 5, 2022

  Based on interview and record review, the facility failed to implement measures to prevent the development of pressure injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) for one resident (Resident 1) of two sampled residents when the facility was unable to provide documented evidence that preventative measures for skin breakdown were an active part of Resident 1's care and skin was not assessed on a regular basis. This failure resulted in Resident 1 developing eight pressure injuries. Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Apr 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was free from abuse when staff witnessed Resident 2's hand under Resident 1's shirt caressing her breast. This failure resulted in sexual abuse and a negative impact on Resident 1's psychosocial sense and dignity. Findings: Resident 1 was readmitted to the facility in early 2021 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Minimum Data Sheet (MDS - an assessment tool), dated 8/21/21, indicated severe memory problems. Resident 2 was admitted to the facility middle of 2018 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Oct 24, 2024

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, patternF606Jun 25, 2026

  Based 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.Findings:During an interview on 6/25/26 at 1:51 p.m., the Human Resources Manager (HRM) stated prior to hiring an employee the facility will run a criminal background check to determine if the candidate for employment was appropriate with the role/position they are applying for.During an interview on 6/25/26 at 2:26 p.m., the Director… […]