Health 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 Page 1 of 2 056495 056495 02/03/2024 Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670

F 0607 Level of Harm - Minimal harm or potential for actual harm was located in CNA 1's personnel file. The document indicated, I (blank) have viewed the abuse video and abuse inservice training. The signature and date sections were blank (not signed or dated). RESIDENT RIGHTS TRAINING. I (blank) have viewed the resident rights video and training. The signature and date sections were blank. The DSD stated CNA 1 should have received the above trainings prior to being assigned to provide care to residents. Residents Affected - Few During an interview and record review on 2/1/24 at 11:45 a.m., the ADM stated CNA 1's reference checks were not done because it is not a requirement. The ADM acknowledged that CNA 1 was not offered mandated abuse and dementia trainings. The ADM stated the DSD was out and, in her absence, he would have expected the Director of Nursing (DON) or the Assistant DON to conduct the mandated trainings for CNA 1. The ADM added, Should be done prior to employment .I trust my team, but apparently it was not done. A review of the facility's 'Resident Rights Guidelines for All Nursing Procedures,' policy dated 10/2010, indicated, Prior to having direct care responsibilities for residents, staff must have appropriate .training on resident's rights, including: preventing, recognizing and reporting resident abuse. A review of the facility's policy titled, Abuse Prevention Program, dated 12/2016 indicated, Our residents have the right to be free from abuse, neglect .exploitation .As part of the resident abuse prevention, the administration will .protect our residents from abuse .Require staff training,/orientation programs that include such topics .abuse prevention, identification and reporting abuse, stress management, and handling verbally and physically aggressive resident behavior. 056495 Page 2 of 2