Health inspection·March 11, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure physician's orders were implemented for one of five sampled residents (Resident 1) when an order for a topical (used on the skin) cream used for pain was not entered from the hospital orders into Resident 1's medication orders. Residents Affected - Few This failure resulted in Resident 1 not having access to her topical pain cream. Findings: Resident 1 was admitted to the facility late 2023 with diagnoses which included respiratory failure and muscle weakness. During a review of Resident 1's AFTER HOSPITAL CARE, dated 12/13/23, the document indicated, Medication List .MISCELLANEOUS CREAMS TOPI (sic) Apply to the affected area if needed [arthritis pain]. Indications: arthritis pain [brand name of cream, over the counter used for pain]. During a review of Resident 1's Order Summary Report [OSR], dated 12/13/23, the OSR does not have (brand name of cream) listed as an order. During a review of Resident 1's Progress Notes [PN], Type: NURSE PROGRESS NOTE, dated 12/17/23 at 6:02 a.m. the PN indicated, Resident c/o [complains of] pain to neck and back with little relief from Tylenol. Resident requesting [something stronger] as stating she did not sleep due to pain . During a review of Resident 1's PN, dated 12/20/23 at 12:20 p.m., the PN indicated, Resident complains of pain throughout the shift .resident does complain of pain before the next dose is able to be administered . During a review of Resident 1's PN, Type: PHYSICIAN PROGRESS NOTE, dated 12/20/23 at 4:14 p.m. the PN indicated, .patient noting back and neck pain . During an interview on 3/11/24 at 12:44 p.m. with Registered Nurse (RN) 1, RN 1 was asked the process for new admission medication orders and stated, All hospital orders go on the MAR [Medication Administration Record] .any medication that the doctor orders go onto the MAR. During an interview on 3/11/24 at 2 p.m. with the Director of Nursing (DON), the chart for Resident 1 was reviewed, the DON was asked if (brand name of cream) was considered a physician order and the DON stated, Yes, they are all physician orders, especially for pain. During a concurrent interview and record review on 3/11/24 with the DON at 2:19 p.m. the physician (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555180 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)