Inspection·February 2, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he left the facility unaccompanied and without staff knowledge and wandered 3 buildings away from the facility that is located next to a busy cross street. This failure placed Resident 1 at high risk for being hit by a moving vehicle, falls, and potentially endangered his life. Findings: A review of the admission Record indicated the facility admitted Resident 1 recently with multiple diagnoses which included dementia (a decline in memory or other thinking and reasoning skills), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness. A review of the physician orders dated 1/14/24 indicated, Resident [1] is NOT Capable of Understanding Rights, Responsibilities, And Informed Consent. A review of the admission assessment dated [DATE] at 4:23 p.m., indicated Resident 1 was oriented to person and had trouble falling asleep. The admitting nurse documented that the resident had poor trunk control and history of falls. A review of Resident 1's 'Fall Risk Assessment,' dated 1/14/24, indicated he was at high risk for falls. A review of LN 1's progress notes dated 1/14/24 at 10:26 p.m., indicated, .Resident [1] was found down the street about 3 apt.[apartment] buildings away accompanied by Fire Dept [Department] paramedics .Resident was knocking on someone's apt door and they called 911. A review of Resident 1's ' Elopement -Wandering Risk,' dated 1/15/24, indicated he scored 7 out of 18 which indicated he was at moderate risk of elopement. A review of nursing progress notes dated 1/18/24 at 1:42 a.m., indicated, Resident [1] is unable to sit still and wanders around the nursing station and hallway .resident .needs multiple redirection. A review of Residents 1's 'Change in Condition' note, dated 1/19/24 at 2:43 p.m., indicated, Resident tried to leave the facility 3 [three] times this morning. Was able to stop him at the door and (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: 056495 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 02/02/2024 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)