Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gold Country Health Center during CMS and state inspections, most recent first.
A resident dependent on staff for ADLs, including bathing, was not provided a scheduled shower for five days, despite being on a regular shower schedule. The resident reported feeling unclean and dissatisfied, and staff interviews confirmed the missed showers were not documented as refusals. This lapse did not align with facility policy to promote resident dignity and well-being.
The facility failed to maintain food safety standards, with a dirty microwave, improperly stored wet pans, and spoiled produce not discarded. Additionally, a dietary aide was unable to correctly verbalize the manual dishwashing procedure, posing a potential risk of food-borne illness to 59 residents.
The facility failed to maintain a clean environment due to improperly secured garbage dumpsters. All three dumpsters outside had bent and deformed lids, preventing secure closure. The Dietary Supervisor confirmed the need for new bins and acknowledged the importance of tightly closed lids to prevent pest issues. Facility policy and FDA Food Code require sealed, leak-proof containers with tight-fitting lids for food waste, which was not adhered to, posing a risk for pest infestation and disease spread.
The facility failed to follow prescribed therapeutic diets for residents, including incorrect food textures and portions for those on dysphagia mechanical, controlled carbohydrate, and finger food diets. These errors were confirmed by the Registered Dietitian and Dietary Supervisor, potentially compromising residents' medical and nutritional status.
A facility failed to maintain a homelike environment for a resident when the chain to operate the overhead light in the resident's room was broken and unreachable. This issue persisted since the resident's admission, preventing them from independently controlling the light. Both a nurse and the DON acknowledged the problem, confirming the chain was too short and should have been replaced immediately, as per the facility's policy on providing adequate lighting.
A resident developed a stage four pressure ulcer on the left sacrum, but the facility failed to complete a Significant Change in Status Assessment (SCSA). The Minimum Data Set Coordinator did not consider the ulcer a significant change, contrary to the Director of Nursing's view. This oversight reduced the facility's ability to provide appropriate care based on the resident's condition.
A resident with a stage four pressure ulcer was inaccurately coded in the MDS as having a deep tissue injury and unstageable wound, despite assessments indicating otherwise. The MDS Coordinator made this decision, believing these conditions were worse than a stage four PU, which contradicted the facility's policy. This misclassification could lead to inadequate wound care management.
A facility failed to create a comprehensive care plan for a resident with a pathological fracture who required a leg immobilizer. The absence of a care plan was confirmed by a nurse and the DON, who acknowledged that the plan should have been developed promptly to ensure timely implementation. The facility's policy mandates comprehensive care plans with measurable objectives, which was not followed in this instance.
A resident with a pathological fracture of the right distal femur was observed using a knee/leg immobilizer without a physician's order. The facility's policy requires immediate recording of physician orders, which was not followed, leading to a deficiency in meeting professional standards of care.
A resident with upper extremity weakness and cerebral infarction was not assisted with wearing hearing aids as ordered, leading to communication difficulties. Observations confirmed the resident was not wearing the aids, which were out of reach, and staff failed to provide necessary assistance.
The facility failed to follow infection control practices for two residents. A nurse did not wear the required N-95 mask for a resident on droplet precaution due to COVID-19, and Enhanced Barrier Precautions were not implemented for a resident with a stage three pressure ulcer. The absence of proper PPE and EBP signage increased the risk of infection spread.
A facility failed to ensure a call light was within reach for a resident with dementia, who required assistance with personal care. During an observation, the call light was found clipped to the head side of the mattress, behind the resident, making it inaccessible. A CNA confirmed the call light was out of reach, and the DON acknowledged the potential for missed care and falls. The facility's policy requires call lights to be accessible to residents.
A resident with respiratory failure and coronavirus disease was transferred to the hospital due to a significant change in condition, but the facility failed to complete required documentation, including a change of condition form, hospital transfer form, and family notification. Interviews with staff confirmed the absence of these documents, which is against the facility's policies.
Failure to Provide Scheduled Showers Compromises Resident Dignity
Penalty
Summary
A resident with diagnoses including spinal stenosis, weakness, gait and mobility abnormalities, and lower back pain was admitted to the facility and required assistance with activities of daily living, including bathing. According to the resident's Minimum Data Set and care plan, staff were responsible for providing this assistance. The resident was scheduled to receive showers on specific days, as indicated by the facility's shower schedule. However, documentation and interviews revealed that the resident did not receive a shower for five consecutive days, receiving only a bed bath at the beginning of this period and a shower at the end. The resident reported feeling unclean and expressed dissatisfaction to CNAs about not receiving a shower, specifically mentioning that her hair became matted and dirty, which negatively affected her well-being. Staff interviews and record reviews confirmed that the resident's scheduled showers were missed and not documented as refusals. The Director of Staff Development and the DON both acknowledged that the resident did not receive bathing services as scheduled and that this was not in accordance with facility policy. The facility's policy emphasized the importance of promoting residents' sense of well-being, satisfaction, and self-worth, which was not upheld in this instance. The failure to provide scheduled showers was identified through observation, interviews, and record review, and was recognized as a lapse in maintaining the resident's dignity.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen microwave was found to be dirty with dried liquid splashes, which the Dietary Supervisor confirmed should have been cleaned. Additionally, several metal sheet pans were improperly stored while still wet, which the Dietary Supervisor acknowledged could lead to bacterial growth. Produce items, including potatoes and onions, were found to be spoiled and not discarded, with the potatoes exhibiting mold and a foul odor, and the onions attracting gnats and having a mushy liquid at the bottom of their storage container. Furthermore, a dietary aide was unable to correctly verbalize the procedure for manual dishwashing using a 3-compartment sink, incorrectly stating the immersion time for sanitizing dishes. The Dietary Supervisor also admitted to not knowing the correct immersion time due to a recent change in supply vendors. These deficiencies in food storage, preparation, and staff knowledge posed a potential risk of food-borne illness to the 59 residents receiving food from the kitchen.
Improperly Secured Garbage Dumpsters
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors due to improperly secured garbage dumpsters. During an observation and interview with the Dietary Supervisor, it was noted that all three dumpsters outside the facility had bent and deformed lids, which prevented them from being securely closed. This condition was confirmed by the Dietary Supervisor, who acknowledged the need for new trash bins and the importance of tightly closed lids to prevent pest issues. The facility's policy requires all food waste to be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and the FDA Food Code mandates that outside receptacles for refuse containing food residue must have tight-fitting lids. The failure to comply with these standards posed a potential risk for pest infestation and disease spread.
Failure to Follow Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to adhere to prescribed therapeutic diets for residents during lunch meals on two consecutive days. Resident 257, who was on a dysphagia mechanical texture diet, received incorrect food textures on both days. On the first day, the resident was served puree zucchini instead of the required chopped and mashable zucchini. On the following day, the resident received a puree apple bread pudding instead of the specified chopped and soaked version. These discrepancies were confirmed by the Registered Dietitian, who acknowledged that the menu was not followed as per the facility's spreadsheet. Additionally, Resident 21, who was on a controlled carbohydrate diet, received a full slice of garlic breadstick instead of the prescribed half slice, which could potentially affect blood sugar levels. Resident 20, on a finger food diet, was served a regular apple bread pudding in one piece rather than the required four pieces. The Dietary Supervisor confirmed the error in serving size. These failures in following the dietary plans had the potential to compromise the medical and nutritional status of the residents involved.
Failure to Maintain Homelike Environment Due to Broken Light Chain
Penalty
Summary
The facility failed to provide a homelike environment for Resident 42, as observed during a survey. The deficiency was identified when the chain used to operate the overhead light in Resident 42's room was found to be broken and unreachable, approximately three inches long. This issue was present since the resident's admission in early September 2024, as confirmed by Resident 42, who expressed that the broken chain prevented him from turning the light on or off independently. During observations and interviews, both a Licensed Nurse and the Director of Nursing acknowledged the problem, confirming that the chain was too short for the resident to reach and should have been replaced immediately. The facility's policy on maintaining a homelike environment, which includes providing comfortable and adequate lighting, was not adhered to in this instance.
Failure to Complete SCSA for Resident with Stage Four Pressure Ulcer
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who developed a stage four pressure ulcer on the left sacrum. The resident, admitted in August 2024 with diagnoses including morbid obesity and diabetes, was observed with a wound vacuum on her lower back. A Change in Condition note dated July 5, 2024, indicated the development of the stage four pressure ulcer, which was confirmed by the treatment nurse and diagnosed by the wound doctor. Despite this significant change in the resident's condition, the Minimum Data Set Coordinator (MDSC) did not complete the SCSA, as she did not consider the facility-acquired stage four pressure ulcer a significant change. The Director of Nursing, however, stated that a stage four pressure ulcer should be considered a significant change, and the SCSA should have been completed to reflect the resident's current status. This oversight decreased the facility's potential to provide appropriate care and services to the resident based on her status.
Inaccurate MDS Coding of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically regarding a pressure ulcer (PU). The resident, who was admitted with diagnoses including morbid obesity and diabetes, had a stage four PU on the left sacrum. Upon readmission to the facility after a hospital visit, the Treatment Nurse (TN1) confirmed the presence of the stage four PU. However, the MDS Quarterly Assessment inaccurately coded the wound as a deep tissue injury and unstageable, despite the skin assessment indicating it was a stage four PU. The MDS Coordinator (MDSC) decided to code the wound as a deep tissue injury and unstageable, believing these conditions were worse than a stage four PU. This decision was contrary to the facility's policy, which requires accurate resident assessments. The Director of Nursing (DON) confirmed that the MDSC should have coded the wound as a stage four PU to ensure appropriate wound care management. This misclassification had the potential to result in inadequate wound care for the resident.
Failure to Develop Comprehensive Care Plan for Resident's Leg Immobilizer
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 208, who was admitted with a diagnosis of a pathological fracture of the right distal femur. During an observation, the resident was seen wearing a right leg immobilizer while seated in a wheelchair. However, upon review of the resident's care plan, it was found that there was no documentation addressing the use of the leg immobilizer. This oversight was confirmed during an interview with a Licensed Nurse, who could not locate a care plan for the immobilizer, and the Director of Nursing, who acknowledged the absence of the care plan and stated that it should have been developed as soon as the order was received to prevent delays in implementation. The facility's policy requires a comprehensive care plan with measurable objectives and timetables for each resident, which was not adhered to in this case.
Failure to Obtain Physician Order for Knee/Leg Immobilizer
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for one of the sampled residents, Resident 208. Resident 208 was admitted in September 2024 with a diagnosis of a pathological fracture of the right distal femur. During observations on September 23, 2024, Resident 208 was seen using a right knee/leg immobilizer while seated in a wheelchair. Treatment Nurse 1 confirmed that the resident had been using the immobilizer since admission. However, upon review of Resident 208's Order Summary Report, Licensed Nurse 1 and the Director of Nursing found no physician's order for the use of the knee/leg immobilizer. The facility's policy requires that physician orders be signed, dated, and recorded immediately to ensure accurate delivery of care, which was not adhered to in this case.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with using hearing aids as ordered, which was an ancillary service required for the resident's care. The resident, who was admitted with diagnoses including weakness of upper extremities and cerebral infarction, was observed on multiple occasions without wearing his hearing aids. The resident reported that staff did not assist him in putting on the hearing aids, and he was unable to do so himself due to his physical limitations. Observations and interviews with staff, including a licensed nurse and the Director of Nursing, confirmed that the resident was not wearing his hearing aids as per the order. The hearing aids were found on the nightstand, out of the resident's reach, indicating a lack of assistance from the nursing staff. The facility's policy on assistive devices and equipment, which includes hearing aids, was not followed, leading to the resident's increased difficulty in hearing and communicating effectively.
Infection Control Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for two residents. For Resident 24, who was on droplet precaution due to a COVID-19 infection, Licensed Nurse 4 (LN 4) did not wear the required N-95 mask while providing care. Instead, LN 4 wore only a surgical mask while administering medications, despite the presence of a droplet precaution sign on the resident's door. This was confirmed during an interview with LN 4, who acknowledged the oversight. The Director of Nursing (DON) stated that staff are expected to follow proper infection control practices to prevent the spread of infection. For Resident 15, who had a stage three pressure ulcer, Enhanced Barrier Precautions (EBP) were not implemented. During an observation, it was noted that there was no EBP sign on the door, and no personal protective equipment (PPE) supplies were available in the designated drawer in the resident's room. LN 3 confirmed the absence of the EBP sign and supplies. The DON acknowledged that the missing EBP sign and protective supplies increased the risk of spreading infection to Resident 15, other residents, and staff.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 18. Resident 18 was admitted to the facility in February 2023 with diagnoses including dementia and a need for assistance with personal care. During an observation and interview on September 23, 2024, it was noted that Resident 18 was sitting in a chair next to her bed, and her call light was clipped to the head side of the mattress, behind her, making it inaccessible. Certified Nursing Assistant 1 confirmed that the call light was out of reach and stated that it should have been placed in front of Resident 18. The Director of Nursing acknowledged that the call light being out of reach could have resulted in missed care and potential falls, emphasizing that staff must ensure call lights are accessible to all residents. A review of the facility's policy and procedure titled 'Answering Call Light,' dated 2022, indicated that call lights should be accessible to residents. This oversight decreased Resident 18's potential to receive timely assistance from staff when needed.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident who was admitted with diagnoses including respiratory failure and coronavirus disease. During a record review, it was found that essential documentation, such as a change of condition (COC) form, a hospital transfer form, and family notification, was missing from the resident's chart after they were transferred to the hospital due to a significant change in condition. Interviews with a Licensed Nurse (LN) and the Director of Nursing (DON) confirmed the absence of these documents. The facility's policies require that a nurse notify the resident's representative and complete necessary documentation when there is a significant change in the resident's condition, which was not done in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Placerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Slope Health Center | 2.4 mi | — | 11 | 0 |
| The Pines At Placerville Healthcare Center | 2.5 mi | — | 14 | 0 |
| Folsom Care Center | 18.4 mi | — | 3 | 0 |
| Rock Creek Care Center | 18.5 mi | — | 9 | 0 |
| Auburn Ravine Healthcare Center | 19.2 mi | — | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.