Health inspection·August 20, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based 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. Findings: Resident 1 was admitted to the facility in March of 2025 with diagnoses which included heart failure and heart disease from plaque (fat, cholesterol, calcium and other substance inside the walls of the arteries that could cause a blood clot or limit blood flow) buildup. A review of Resident 1's Order Summary Report (ORS), 4/1/25, indicated, Resident has capacity to make his decisions related to. A review of Resident 1's Progress Notes (PN), dated 6/10/25, indicated, Type: IDT [Interdisciplinary Team] NOTE. He [Resident 1] has been observed independently walking throughout facility and is not a risk for contractures; appropriate for D/C [discharge] form [from] RNA [Restorative Nursing Assistant] program at this time. A review of Resident 1's PN dated, dated 6/20/25, The PN indicated, Type: IDT NOTE. OT [Occupational Therapy] conducted AE [Adverse Event] audit; met with resident to assure that they were able to independently and efficiently feed themselves with/without AE. [Resident 1's name] is independent with feeding with/without AE.A review of Resident 1's Nursing - Weekly Summary (NWS), dated 6/29/25, indicated Resident 1 was independent with ADL's (Activities of Daily Living) which included: Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. A review of Resident 1's NWS, dated 7/27/25, indicated that Resident 1 was independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's NWS, dated 8/3/25, indicated that Resident 1 remains independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's Care Plan (CP), dated 8/1/24, indicated, Expresses/indicates a preference to: Return home with part time caregiver.Projected stay is expected to be of short durationA review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 8/2/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating a normal cognitive function and indicated Resident 1 was independent in all Functional Abilities which included eating, toileting, showering, transferring and walking. A review of Resident 1's PN, dated 8/13/25, indicated, Type: Social Service Note.It is noted that this res [Resident 1] does not need or require SNF [Skilled Nursing Facility] level of care, it has been determined he no longer meets the Medicare or Medicaid guidelines for Residents Affected - Few Page 1 of 6 055497 055497 08/20/2025 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few continued nursing home care.During an interview on 8/20/25 at 12:20 p.m., with the License Nurse (LN) 1, LN 1 stated that Resident 1 was independent in performing all ADLs and required assistance only with medication administration. LN 1 further stated that the resident was consistently compliant with his medications.During an interview on 8/20/25 at 12:30 p.m., with the License Nurse Supervisor (LNS), LNS stated that Resident 1 was, Extremely independent and he has his own primary care doctor. During an interview on 8/20/25 at 12:43 p.m. with the Social Services Director (SSD), the SSD stated that Resident 1 was fully independent and did not require SNF level of care. The SSD also stated, He does everything on his own. I explained to them that he does not need this level of care and there are other options that fit his needs. The SSD further described Resident 1 as high functioning. During an interview on 8/20/25 at 1:35 p.m., with Director of Nursing (DON), the DON stated, [Complainant] came to me a couple of months ago and began questioning why the patient does not have physician assessments in his chart. I explained to her that he has a doctor outside of the facility and that he is in total care of [Resident 1's name]. The DON stated, He [Resident 1's primary care physician (PCP)] would call me after hours and explain to me that he will get information to me the next business day, that did not happen. The DON further stated that [Complainant] requested justification for the patient's need for SNF level care. During a telephone interview on 8/21/25 at 2:40 p.m. with the DON, the DON confirmed that Resident 1 was stable and independent, and based on facility documentation and assessments, the resident did not require a SNF level of care. The DON further stated, The facility was also investigating this incident involving his stay since last May without any clinical justifications.A review of the facility document from the Medical Director (MD), dated 8/22/25, the document indicated, I have been asked to review this patient's medical history and functional status in order to assist with the determination of the patient's medical necessity to be in skilled nursing setting. There has not been any documented functional decline observed by staff here at the nursing facility. It has been recommended that he transition to a lower level of care as he is too high functioning for the nursing home setting. In contrast to the facility's assessments and staff interviews of Resident 1, Resident 1's PCP's email to the DON on 8/21/25 indicated, Patient is forgetful and poses a safety risk with regards to medication management and IADLs [sic]. will need constant supervision. This letter is being written for the purpose of recommendations for the continued SNF stay for the patient. During a follow-up phone interview on 8/21/25 at 4:50 p.m. with the DON, The DON stated that after receiving an email from Resident 1's PCP containing justification for the resident's continued need for SNF level of care, the facility reviewed the information and did not agree with the PCP's justification. The DON also confirmed that there were communication issues between the facility and Residents 1's PCP and inconsistencies regarding Resident 1's assessments for SNF level of care.During a phone interview on 8/26/25 at 3:08 p.m. with the MD, the MD acknowledged that there was communication and documentation issues between Resident 1's PCP and the facility. The MD confirmed that Resident 1 did not require skilled nursing SNF level of care.During a telephone interview on 8/28/25 at 3:12 p.m., the DON stated that she had obtained documents from Resident 1's PCP for the resident's past assessments. The DON confirmed that those documents had not been entered into the resident's medical record prior to their receipt. On 8/28/25, the DON provided via secured email the PCP's past assessments, TYPE: Physician Progress Notes (Narrative) for Resident 1 which she obtained that day, included those dates 08/14/25, 07/18/25, 06/20/25, 05/02/25, 04/18/25, 03/5/25, 02/07/25, 01/08/25, 12/20/24, and 11/20/24.Review of the facility's policies and procedures (P&P) titled, Charting and Documentation, dated 7/17, the P&P indicated, All services provided to the resident. shall be documented in the resident's medical record. Documentation in the medical record will be. 055497 Page 2 of 6 055497 08/20/2025 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0641 complete, and accurate.A Review of the facility P&P titled, Charting Errors and/or Omissions, dated, 12/06, the P&P indicated, Accurate medical records shall be maintained by this facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055497 Page 3 of 6 055497 08/20/2025 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Based 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. Findings: Resident 1 was admitted to the facility in March of 2025 with diagnoses which included heart failure and heart disease from plaque (fat, cholesterol, calcium and other substance inside the walls of the arteries that could cause a blood clot or limit blood flow) buildup. A review of Resident 1's Order Summary Report (ORS), 4/1/25, indicated, Resident has capacity to make his decisions related to. A review of Resident 1's Progress Notes (PN), dated 6/10/25, indicated, Type: IDT [Interdisciplinary Team] NOTE. He [Resident 1] has been observed independently walking throughout facility and is not a risk for contractures; appropriate for D/C [discharge] form [from] RNA [Restorative Nursing Assistant] program at this time. A review of Resident 1's PN dated, dated 6/20/25, The PN indicated, Type: IDT NOTE. OT [Occupational Therapy] conducted AE [Adverse Event] audit; met with resident to assure that they were able to independently and efficiently feed themselves with/without AE. [Resident 1's name] is independent with feeding with/without AE. A review of Resident 1's Nursing - Weekly Summary (NWS), dated 6/29/25, indicated Resident 1 was independent with ADL's (Activities of Daily Living) which included: Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. A review of Resident 1's NWS, dated 7/27/25, indicated that Resident 1 was independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's NWS, dated 8/3/25, indicated that Resident 1 remained independent with ADL's which included Bed Mobility, Transfer and Dressing. The NWS also indicated that Resident 1's Oral Intake scored an average of 100%, which means that Resident 1 was consuming all the food and fluids offered to him. The NWS also indicated Resident 1 was alert and oriented to person, place, time and situation indicating full cognitive awareness. A review of Resident 1's Care Plan (CP), dated 8/1/24, indicated, Expresses/indicates a preference to: Return home with part time caregiver.Projected stay is expected to be of short duration A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 8/2/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating a normal cognitive function and indicated Resident 1 was independent in all Functional Abilities which included eating, toileting, showering, transferring and walking. A review of Resident 1's PN, dated 8/13/25, indicated, Type: Social Service Note.It is noted that this res [Resident 1] does not need or require SNF [Skilled Nursing Facility] level of care, it has been determined he no longer meets the Medicare or Medicaid guidelines for continued nursing home care. During an interview on 8/20/25 at 12:20 p.m., with the License Nurse (LN) 1, LN 1 stated that Resident 1 was independent in performing all ADLs and required assistance only with medication administration. LN 1 further stated that the resident was consistently compliant with his medications. During an interview on 8/20/25 at 12:30 p.m., with the License Nurse Supervisor (LNS), LNS stated that Resident 1 was, Extremely independent and he has his own primary care doctor. During an interview on 8/20/25 at 12:43 p.m. with the Social Services Director (SSD), the SSD stated that Resident 1 was fully 055497 Page 4 of 6 055497 08/20/2025 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few independent and did not require SNF level of care. The SSD also stated, He does everything on his own. I explained to them that he does not need this level of care and there are other options that fit his needs. The SSD further described Resident 1 as high functioning. During an interview on 8/20/25 at 1:35 p.m., with Director of Nursing (DON), the DON stated, [Complainant] came to me a couple of months ago and began questioning why the patient does not have physician assessments in his chart. I explained to her that he has a doctor outside of the facility and that he is in total care of [Resident 1's name]. The DON stated, He [Resident 1's primary care physician (PCP)] would call me after hours and explain to me that he will get information to me the next business day, that did not happen. The DON further stated that [Complainant] requested justification for the patient's need for SNF level care. During a telephone interview on 8/21/25 at 2:40 p.m. with the DON, the DON confirmed that Resident 1 was stable and independent, and based on facility documentation and assessments, the resident did not require a SNF level of care. The DON further stated, The facility was also investigating this incident involving his stay since last May without any clinical justifications. A review of the facility document from the Medical Director (MD), dated 8/22/25, the document indicated, I have been asked to review this patient's medical history and functional status in order to assist with the determination of the patient's medical necessity to be in skilled nursing setting. There has not been any documented functional decline observed by staff here at the nursing facility. It has been recommended that he transition to a lower level of care as he is too high functioning for the nursing home setting. In contrast to the facility's assessments and staff interviews of Resident 1, Resident 1's PCP's email to the DON on 8/21/25 indicated, Patient is forgetful and poses a safety risk with regards to medication management and IADLs [sic]. will need constant supervision. This letter is being written for the purpose of recommendations for the continued SNF stay for the patient. During a follow-up phone interview on 8/21/25 at 4:50 p.m. with the DON, The DON stated that after receiving an email from Resident 1's PCP containing justification for the resident's continued need for SNF level of care, the facility reviewed the information and did not agree with the PCP's justification. The DON also confirmed that there were communication issues between the facility and Residents 1's PCP and inconsistencies regarding Resident 1's assessments for SNF level of care. During a phone interview on 8/26/25 at 3:08 p.m. with the MD, the MD stated, I have not worked with Resident 1's PCP, and I do not have a professional relationship with him. I cannot discharge a patient that is not mine. She further stated, I am not his PCP; I am just the Medical Director for the whole building. The MD also acknowledged that there were communication and documentation issues between Resident 1's PCP and the facility. Additionally, the MD confirmed that Resident 1 does not require skilled nursing facility (SNF) level of care and stated, everyone in the facility believes he is ready but [PCP name]. During a phone interview on 9/2/25, at 3:21 p.m. with the DON, when asked about the Medical Director's role in relation to discrepancy with assessments, the DON stated that considering the MD had already provided her opinion on the matter, The DON cannot force Resident 1 to be followed by the MD. The DON further stated that based on observations and the information available to the MD, The MD has expressed her professional judgment. The DON further stated that the situation ultimately falls within the ethical boundaries and discretion of the physicians involved. A review of the facility Policy and Procedures (P&P) titled, Medical Director, dated 4/25, the P&P indicated, The medical director is responsible for implementation of resident care policies and coordination of medical care in the facility. Coordination of medical care in the facility includes: actively participating in the facility assessments. implementing and supervising resident care policies and practices . intervening with a health care practitioner regarding medical care. A review of the facility document titled, 055497 Page 5 of 6 055497 08/20/2025 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MEDICAL DIRECTORSHIP AGREEMENT, the agreement indicated, Medical Director Roles.The medical director is involved in all levels of individualized patient care and supervision, and for all persons served by the facility. Role 1 - Physician Leadership. The medical director helps serve as the physician responsible for overall care and clinical practices carried out at the facility. Other Expectations. Developing a liaison with attending staff physicians to ensure that the patients in the Facility receive effective and prompt medical care. 055497 Page 6 of 6