Inspection·February 3, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their abuse policy and procedure when abuse, dementia and resident's rights trainings including reference checks were not completed for one of 6 employees (Certified Nursing Assistant, CNA 1) prior to being assigned to provide care to residents. Residents Affected - Few This failure placed the residents at risk for abuse, neglect and mistreatment. Additionally, the failure to provide CNA 1 with abuse prevention and reporting training denied her the ability to recognize incidents of abuse and the process for reporting such incidences. Findings: A review of the facility's policy titled, Background Screening Investigations, dated 3/2019 indicated, Our facility may conduct employment background screening checks, reference checks .on all applicants for positions with direct access to residents. An interview related to the facility reported incident for allegation of staff to resident abuse was conducted with the facility's Administrator (ADM) on 2/1/24 at 10:35 a.m. The ADM stated Resident 2 reported that her roommate (Resident 1) was verbally and physically abused the previous evening by CNA 1 during transfer from wheelchair to her bed. The ADM stated the facility immediately suspended CNA 1 and the abuse investigation was started. The ADM stated the facility interviewed other staff and residents and was not able to substantiate the abuse allegation. During an interview on 2/1/24 at 11 a.m., CNA 1 stated she was assigned to provide care to Resident 1 on 1/28/24 and 1/29/24. CNA 1 denied the allegation that she verbally and physically abused Resident 1. CNA 1 stated another staff (CNA 6) who was assisting her with transferring Resident 1 to bed would corroborate that no abuse occurred. CNA 1 stated as part of her training, she shadowed other CNAs for 3 days before she started providing resident care on her own. CNA 1 stated she was not offered and did not receive any training related to abuse, dementia, and resident's rights. During a concurrent interview and review of CNA 1's personnel file on 2/1/24 at 11:25 a.m., the Director of Staff Development (DSD) stated CNA 1 was hired on 1/22/24 while the DSD was on leave. CNA 1's personnel file did not contain previous employment and reference checks and the DSD verified they were missing. A further review of CNA 1's personnel file in the presence of the DSD, indicated there was no evidence CNA 1 had completed the mandated abuse prevention and dementia training provided by the facility before being assigned to provide care to residents. The DSD confirmed CNA 1's personnel file contained forms related to Reporting Elder and Dependent Adult Abuse, Sexual Harassment, Dementia Training Acknowledgement, and Statement of Acknowledgement of Resident's Rights forms that were not acknowledged or signed by CNA 1. Upon further review, a blank document titled ABUSE TRAINING (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 02/03/2024 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)