Health inspection·June 13, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to promote dignity for one of three sampled residents (Resident 2), when the resident was not provided shower for five days. Residents Affected - Few This failure had the potential to result in Resident 2 ' s not attaining her feelings of self-worth and self-esteem. Findings: Resident 2 was admitted to the facility in spring 2025 with diagnoses which included spinal stenosis (narrowing of the spine), weakness, gait (walking) and mobility (moving) abnormalities, and lower back pain. During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 6/6/25 , the MDS indicated Resident 2 required assistance with activities of daily living (ADLs), including bathing. During a concurrent observation and interview on 6/12/25 at 9:40 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 was awake, alert and verbally responsive, and stated, I voiced my concern about not getting a shower quite a bit to the CNA ' s (Certified Nursing Assistant). My hair was so matted and dirty it didn ' t make me feel good at all. During a concurrent interview and record review on 6/12/25 at 10a.m. with CNA 1, the Skilled Nursing Shower Schedule, dated April 2025 was reviewed. The Skilled Nursing Shower Schedule indicated, Resident 2 ' s regular scheduled shower days were Monday and Thursday. CNA 1 indicated residents were scheduled on certain days for showers and CNA 1 would have expected residents to have a shower on their regular scheduled day unless documented as refusal. During a concurrent interview and record review on 6/12/25 at 10:14 a.m. with Director of Staffing Development (DSD), the undated Shower Tracking Sheet was reviewed. The Shower Tracking Sheet indicated, Resident 2 received a bed bath on 6/4/25 and a shower on 6/11/25. DSD confirmed Resident 2 did not receive her scheduled bath. During an interview on 6/12/25 at 1 p.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated completed and refused resident baths were documented on the shower tracking sheet. RNA 1 stated residents not having showers could put a resident at risk for infections and made them feel unclean. During a concurrent interview and record review on 6/12/25 at 2 p.m. with the Director of Staff Page 1 of 2 555180 555180 06/13/2025 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Development (DSD), the Follow Up Question Report: Bathing Performed: Shower, Tub Bath, or Bed Bath, dated June 2025, indicated, there were no bathing services provided for Resident 2 for 5 days. The DSD stated, she expected Resident 2 ' s Saturday schedule shower to be in the log. The DSD stated the adverse outcome of not having a shower for a long period of time could lead to skin breakdown. During an interview on 6/12/25 at 1 p.m. with Director of Nursing (DON), the DON stated, she expected staff to follow the shower schedule and document completions and refusals. The DON stated the adverse outcome of missing shower could cause skin breakdown, could cause disinterest, and effect the resident ' s dignity. During a review of Resident 2 ' s Care Plan Report, dated 5/31/25, the Care Plan Report indicated, Resident 2 was dependent on staff for ADLs (bathing). During a review of the facility ' s policy and procedure (P&P) titled, Quality of Care- Dignity, dated 1/22, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 555180 Page 2 of 2