Health inspection·November 29, 2023

F 0692 10/28/23- 175.0 pounds- noted on 11/10/23 to be incorrect entry Level of Harm - Minimal harm or potential for actual harm 10/31/23- 171.0 pounds- noted on 11/10/23 to be incorrect entry, corrected weight 166.0 pounds 11/1/23- 171.0 pounds - noted on 11/10/23 to be incorrect entry Residents Affected - Few 11/7/23- 160.0 pounds 11/10/21- 159.0 pounds A review of Resident 1's Nutritional Risk Assessment, dated 10/16/23, indicated .Weight: 164 Meal % consumption: 25-75%, AVG [Average] 50% x 12 meals (refusal x 1) .Est. [estimated] Calorie Needs: Based on CBW [Current Body Weight] 74.5 kg [kilogram] 2235- 2600kcal [kilocalories-calories]/day .Nutritional Intervention .Regular diet Regular texture .Resident noted with limited/poor dentition reported difficulty chewing and agrees to . diet downgrade options discussed .Recommend: 1) Downgrade diet Mech [mechanical] Soft texture [chopped or ground foods] .2) Health Shake TID [three times a day] at meals .Arginaid [supplement to aid in wound healing] (1 packet) 2xday x 30 days . A review of Resident1's Nutritional Risk Assessment, dated 11/1/23, indicated .Weight: 171.0 .Meal % consumption: 25-100%, AVG 72% on reentry x 14 meals .Est. Calorie Needs: Based on CBW 77.7kg: 2300-2720kcal/day .Nutritional Intervention .Current diet .pureed texture .improved intake noted 89% x 3 days .Current weight 171 lbs [pounds] .Prior admit 10/16/23 164lbs with wt [weight] trends up +7ibs/4.3% .Rec 1)Health Shake TID at meals 2) Arginaid (1 packet) 2xday x 30 days 3) SF Pro-stat [liquid protein supplement] BID [two times a day] x 30 days . A review of Resident 1's Progress Notes, dated 10/27/23, indicated .family is requesting to change the diet, b/c [because] resident doesn't have teeth. Asked [name of MD-medical doctor] if it's OK to change to mechanical soft until evaluated by Dietitian on Monday and MD said OK . A review of Resident 1's Speech Therapy Treatment Encounter Note, dated 10/31/23, indicated .pt [patient] essentially edentulous [lacking teeth] with lower frontal 4 teeth only (poor condition), 1 upper L molar and 1 upper L frontal broken tooth. Pt reported increased difficulty with chewing and managing solid textures d/t [due to] decreased ability to effectively chew d/t poor dentition [arrangement of teeth in the mouth] .pt noting he does not want solid textures and prefers puree as it is easier to manage .Recommend puree diet with thin liquids . A review of Resident 1's (IDT) Interdisciplinary Progress Note, dated 11/9/23, indicated .WEIGHT WARNING .Current weight: 11/7/23 160lbs, indicating weight loss down -11lbs x 1 week .Reentry 10/27/23 175lbs .Prior admit 10/16/23 164lbs .Contributing factors: recurrent hospitalizations s/p [status post] IV [intravenous] ATB [antibiotic] therapy .hx [history] wt gains on return ? weight on return possible taken with wound vac .PO [oral] intake 75-100% most meals documented .Recommend: 1) Ensure (or equivalent) [nutritional supplement] 1carton/8oz [ounces]. 2xday, document % taken 2) Snacks TID between meals . A review of Resident 1's Care Plan, initiated 11/1/23, revised 11/7/23 .Risk for dental discomfort due to: Difficulty with chewing .Goal .Maintain adequate nutritional intake .Interventions/Tasks .Diet as ordered and tolerated .Monitor meal consumption .Monitor weight .Refer to RD [Registered Dietitian] in needed . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 2 of 5 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 056495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's Care Plan, initiated 10/27/23, Indicated .Resident is at [sic] for malnutrition, dehydration, and/or weight change secondary to: Current dx [diagnosis] of Pressure ulcer sacral [lower spine] region stg [stage] 4 [full thickness skin loss that may extend to muscle, tendons, and bone], Pressure ulcer of right hip and right lower leg, Adult Failure to thrive .Goal .The resident will have an average PO intake of ~75% or more .The resident will have stable weight trends .Interventions/Tasks .Notify MD of significant weight changes PRN [as needed] .Regular diet, pureed texture, thin liquids consistency as ordered .Weight monitoring, evaluation, and reporting of significant changes to MD and RP [Responsible Party] per facility policy/procedures or per MD orders . A review of Resident 1's Document Survey Report, for October 2023, indicated intake was recorded only two times a day on 10/16/23. A review of Resident 1's Task: Nutrition-Amount Eaten, for 10/26/23 to 11/10/23, indicated intake was recorded only two times a day on 11/3/23 and 11/4/23. During a telephone interview on 11/7/23 at 4:17 p.m. with Resident 1's Family Member (FM), the FM stated Resident 1 was admitted to the facility after a hospital stay and was placed on a regular diet. The FM stated that Resident 1 only has four teeth and needed a pureed diet. The FM stated, He wasn't able to eat, needed a pureed diet. The FM stated when she saw him two weeks ago at the facility, He couldn't chew the food, needed pureed food. Wasn't able to eat. Was on a regular diet. The FM also stated Resident 1 was put on a mechanical soft diet but still had a hard time. The FM stated Resident 1 was eating more since starting a pureed diet. During an interview on 11/9/23 at 10:38 a.m. with the Director of Nursing (DON) the DON stated Resident 1's admission weight was 164 pounds, weight on 11/1/23 was 171 pounds, and weight on 11/8/23 was 160 pounds. The DON stated the weight loss from 11/1/23 to 11/8/23 may have been due to wound drainage from wound vac on stage 4 pressure ulcer. During an interview on 11/9/23 at 11:25 a.m. with the MD, reviewed Resident 1's weight loss from 11/1/23 to 11/8/23 of 11 pounds. The MD stated Resident 1 may have been weighed incorrectly or the wrong scale was used. The MD stated the Registered Dietitian (RD) is working with Resident 1. During an interview on 11/9/23 at 1:35 p.m. with the RD, reviewed Resident 1's weights including admission weight of 164 pounds, weight on 11/1/23 of 171 pounds, and weight on 11/8/23 of 160 pounds. The RD stated that Resident 1 needed to be reweighed to check the accuracy of the weight. The RD stated she added supplements to Resident 1's diet including Arginaid, Health Shakes with meals, and Pro-Stat. The RD stated on 11/1/23 it was recommended to nursing to restart supplements after return from hospital on [DATE]. The RD stated the supplements were not reordered until 11/7/23. The RD stated the initial Nutritional Risk Assessment, completed on 10/16/23, recommended Resident 1's diet be changed from regular texture to mechanical soft. The RD stated on 10/18/23 the diet was changed to mechanical soft diet. The RD stated Resident 1's diet was regular texture from 10/13/23 to 10/18/23, changed to mechanical soft on10/18/23, on regular diet 10/26/23 to 10/27, and changed to pureed diet 10/28/23. Resident 1 was not able to easily eat a regular or mechanical soft diet. The RD stated she monitors resident's intake based on the CNA's documentation of intake and by talking with the resident. The RD stated that RNAs weighed the residents. During a concurrent interview and record review on 11/9/23 at 2:05 p.m. with the DON, the DON acknowledged that CNAs did not document intake for every meal for Resident 1 from 10/13/23 to 11/9/23. The DON acknowledged that if Resident 1 refused a meal it was not documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 3 of 5 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 056495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 11/9/23 at 2:45 p.m. with Resident 1, Resident 1 was being fed mashed potatoes and gravy by a friend at bedside. Resident 1 stated he is eating okay. Friend stated Resident 1 eats well when she brings food to him. During an interview on 11/9/23 at 3:20 p.m. with CNA 1, CNA 1 stated Resident 1 is fed every meal and is dependent for feeding. CNA 1 stated she documented in the chart how much Resident 1 ate each meal. During an interview on 11/9/23 at 3:35 p.m. with CNA 2, CNA 2 stated Resident 1 was not eating very much when he was on a mechanical soft diet but is eating well on a pureed diet. CNA 2 stated she documented how much Resident 1 ate at each meal in the chart. During an interview on 11/9/23 at 3:40 p.m. with Licensed Nurse (LN) 1, she stated Resident 1 Usually eats 100 %, only pureed diet, can't eat other food. LN 1 stated that how much Resident 1 has eaten is documented in the Task section of the chart. LN 1 stated she was not aware of any weight loss for Resident 1. LN 1 stated if weight loss is identified a Change in Condition is initiated and the MD and RD are notified. During a concurrent interview and record review on 11/9/23 at 4:00 p.m. with CNA 3, CNA 3 acknowledged that he did not chart Resident 1's dinner intake on 11/8/23. CNA 3 stated he usually charts at the end of his shift but was not able to chart yesterday. CNA 3 acknowledged that charting intake is not done consistently. During an interview on 11/9/23 at 4:05 p.m. with the DON, the DON stated that some of Resident 1's weights were incorrect because the RNA weighed Resident 1 with a wound vac attached to the resident. DON stated that the weight of the wound vac varied based on the amount of drainage in cannister. The DON stated that Resident 1 was weighed correctly on 11/7/23 when the wound treatment nurse noticed that Resident 1 was being weighed with wound vac attached and then detached it. The DON stated the RNAs weighed Resident 1 with a Hoyer lift [mechanical device to assist with lifting residents] and wound vac hanging on the Hoyer lift or placed on the bed when weighing. The DON stated the wound vac should have been detached from Resident 1 when being weighed because if placed on the bed, it still affected the weight. The DON stated Resident 1 was reweighed with wound vac detached on 11/9/23 with DON present and weighed 160 pounds. The DON stated Resident 1 was admitted from the hospital with orders for regular diet texture on 10/13/23 and the diet was changed to mechanical soft on 10/18/23. Resident 1 was at the hospital 10/20/23 to 10/26/23. The DON stated when Resident 1 returned from hospital on [DATE], he was placed on a regular diet per the hospital discharge orders. Resident 1's diet was not changed to pureed until 10/28/23. The DON stated that orders prior to readmission on [DATE] did not carry over and there is not a process to review prior orders. During a telephone interview on 11/10/23 at 10:17 a.m. with RNA 1, RNA 1 stated Resident 1 was weighed in Hoyer lift. RNA 1 stated Resident 1 was weighed on 11/9/23 without the wound vac attached and the weight was a lot different. RNA 1 stated, Had been weighing Resident 1 in Hoyer lift with wound vac attached but put on the bed. Don't know why it is different. During a telephone interview on 11/10/23 at 10:25 a.m. and a subsequent interview on 11/10/23 at 2:25 p.m. with the DON, the DON stated the RNAs were putting the wound vac on the bed, but it was still attached to the resident. The tubing and drainage had weight that affected the weight of the resident. The DON stated Resident 1 was reweighed on 11/10/23 and weighed 159 pounds, a 5 pound weight loss in one month. The DON stated that the weighing policy is about recording weights but does not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 4 of 5 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 056495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have the methods of weighing. The DON stated that everything that is connected to a resident should be disconnected from the resident prior to weighing or weights will be inaccurate. The DON stated the RNAs thought that if it was in the bed, they did not need to deduct the weight of the wound vac. The DON acknowledged the RD and MD may have based interventions on weights that were incorrect. A review of the facility's policy and procedure (P&P) titled Food and Nutrition Services, revised 10/17, indicated .Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident .The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization .A resident-centered diet and nutrition plan will be based this assessment .Nursing personnel, with the assistance of food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems .Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse .A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian .A facility Dietitian will help assess the nutritional needs and risks of all residents and patients in the facility, and help the facility assure that it provides appropriate meals and other nutritional interventions . A review of the facility's P&P titled Weight Assessment and Intervention, revised 9/2008, Indicated .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the Weight is verified, nursing will immediately notify the Dietitian in writing .The Dietitian will respond within 24 hours of receipt of written notification .Interventions for undesirable weight loss shall be based on careful consideration of the following . Nutrition and hydration needs of the resident .Chewing and swallowing abnormalities and the need for diet modifications . A review of the facility's P&P titled Therapeutic Diets, revised 11/15, indicated .Mechanically altered diets .will be considered therapeutic diets.Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes .A therapeutic diet must be prescribed by the resident's Attending Physician .The Clinical Dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 5 of 5