Inspection·February 8, 2024

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated PTSD was a mental illness. Per the Director of MDS, if the diagnosis affected the resident's activities of daily living, then the PASARR Level I Screening should be marked as a 'yes' for mental illness. During an interview on 02/07/2024 at 12:51 PM, the Administrator stated Resident #56's PASARR Level I Screening was completed at an outside hospital prior to the resident being admitted to the facility. Per the Administrator, the Director of MDS was responsible for reviewing the PASARR Level I Screening for accuracy. Event ID: Facility ID: 056495 If continuation sheet Page 2 of 6 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 02/08/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interviews, record review, and review of a facility policy, the facility failed to ensure a resident's care plan was revised to include contact precautions for clostridium difficile (C-diff) for 1 (Resident #78) of 8 sampled residents reviewed for infection control. Findings included: Review of a facility policy titled Care Plans, Comprehensive Person Centered, revised in December 2016, revealed 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and o. Reflect currently recognized standards or practice for problem areas and conditions. A review of Resident #78's admission Record revealed the facility admitted the resident on 10/18/2023. Per the admission Record, Resident #78 received a diagnosis of C-diff on 12/12/2023. Review of Resident #78's Order Summary Report, with active orders as of 02/07/2024, revealed an order dated 12/12/2023, for isolation precautions related to C-diff. Review of Resident #78's comprehensive care plan, with an admission date of 10/18/2023, revealed no evidence of a care plan related to the resident's diagnosis of C-diff. During an observation on 02/05/2024 at 9:03 AM, Resident #78 was noted on contact precautions for C-diff. In an interview on 02/07/2024 at 12:25 PM, the Director of Nursing stated the care plan should reflect the resident currently being on contact isolation. In an interview on 02/08/2024 at 12:56 PM, the Administrator stated a resident's care plan should be updated to include the resident's current level of care. The Administrator stated he would expect a resident's care plan to address if a resident was on isolation precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 3 of 6 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 02/08/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record reviews, facility policy reviews, and document review, the facility failed to ensure staff wore personal protective equipment (PPE) when they provided care for 2 (Resident #40 and Resident #78) of 8 sampled residents reviewed for infection control. The facility also failed to ensure fit testing for 3 (Licensed Vocational Nuse #3, Registered Nurse #4, and Certified Nursing Assistant #5) of 4 staff reviewed for fit testing. Residents Affected - Few Findings included: Review of a facility policy tilted Handwashing/Hand Hygiene revised in August 2019, revealed, 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile. 1. A review of Resident #40's admission Record revealed the facility admitted the resident on 05/24/2019. The admission Record revealed the resident received a diagnosis of resistance to multiple antimicrobial drugs on 01/20/2022. A review of Resident #40's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/2023, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Per the MDS, the resident required setup or clean-up assistance for eating. A review of Resident #40's care plan initiated on 01/02/2024, revealed the resident had a history of carbapenem-resistant acinetobacter baumannii infection and was on indefinite isolation. Interventions directed the staff to follow isolation precautions. According to the Morbidity and Mortality Weekly Report, dated 12/04/2020 and published by the Centers for Disease Control and Prevention, Carbapenem-resistant Acinetobacter baumannii (CRAB), an opportunistic pathogen primarily associated with hospital-acquired infections, is an urgent public health threat. In health care facilities, CRAB readily contaminates the patient care environment and health care providers' hands, survives for extended periods on dry surfaces, and can be spread by asymptomatically colonized persons; these factors make CRAB outbreaks in acute care hospitals difficult to control. On 02/06/2024 at 11:46 AM, Resident #40 was observed lying in bed. A contact precautions sign was observed on the resident's door. The Contact Precautions sign revealed staff should clean hands before entering and when leaving room and that a gown and gloves were required. The sign specified, if there was a risk of splash or spray, to wear face and eye protection. During an interview on 02/06/2024 at 12:05 PM, Licensed Vocational Nurse #2 stated Resident #40 was on contact isolation precautions indefinitely for a CRAB infection. On 02/08/2024 at 8:02 AM, Certified Nursing Assistant (CNA) #1 entered Resident #40's room without personal protective equipment (PPE) and removed Resident #40's breakfast tray. During an interview on 02/08/2024 at 8:07 AM, CNA #1 stated she should have put on PPE before she entered Resident #40's room. Per CNA #1, she forgot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 4 of 6 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 02/08/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/08/2024 at 9:24 AM, the Infection Preventionist stated staff were trained to put on PPE for residents on contact isolation precautions before they entered the resident's room to provide care or pick up a resident's meal tray. During an interview on 02/08/2024 at 12:21 PM, the Director of Nursing stated it was her expectation that staff wear the required PPE before they entered a resident's room that was on contact isolation precautions. During an interview on 02/08/2024 at 1:29 PM, the Administrator revealed that it was his expectation that staff follow the guidelines for contact isolation precautions. The Administrator further indicated that staff should have on the proper mask, gown, and gloves. 2. Review of a facility policy titled, Clostridium difficile [C. difficile], revised in October 2018, revealed, Measures are taken to prevent the occurrence of Clostridium difficile infections among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. The policy specified, 4. C. difficile is transmitted via the fecal-oral route. Therefore, any resident-care activity that involves contact with the resident's mouth when hands or instruments are contaminated may provide an opportunity for transmission. The policy indicated, 14. When caring for residents with CDI [clostridium difficile infection], staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR [alcohol-based hand rub] for the mechanical removal of C. difficile spores from hands. A review of Resident #78's admission Record revealed the facility admitted the resident on 10/18/2023. Per the admission Record, Resident #78 received a diagnosis of C. difficile on 12/12/2023. Review of Resident #78's Order Summary Report, with active orders as of 02/07/2024, revealed an order dated 12/12/2023, for isolation precautions related to C. difficile. During an observation on 02/05/2024 at 9:03 AM, Resident #78 was noted on contact precautions for C. difficile. During an observation on 02/06/2024 at 1:22 PM, an aide entered Resident #78's room, without PPE, and handed the resident a water pitcher. During an observation on 02/06/2024 at 2:22 PM, an aide wheeled Resident #78 into the shower room, while only wearing a mask. After use of the shower chair, the aide placed the shower chair back into the shower room, without cleaning and/or disinfecting the shower chair. In an interview on 02/06/2024 at 2:58 PM, Certified Nursing Assistant (CNA) #7 acknowledged she did not have on any PPE when she entered Resident #78's room to hand the resident their water pitcher. CNA #7 also acknowledged she only had a mask on when she wheeled Resident #78 into the shower room. In an interview on 02/06/2024 at 3:35 PM, the Infection Preventionist (IP) stated Resident #78 continued to show symptoms of C. difficile. The IP stated staff should wear PPE when they transported Resident #78 to the shower room. The IP acknowledged staff should have on PPE when they enter the resident's room. In an interview on 02/08/2024 at 11:00 AM, the Director of Nursing stated the staff are required to wear PPE when they have direct contact with a resident who is on contact isolation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 5 of 6 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 02/08/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/08/2024 at 11:40 AM, the Administrator stated the staff must wash their hands and wear PPE when they work with residents who have C. difficile. The Administrator stated the staff must be extra vigilant to ensure the spread of C. difficile did not occur. 3. Review of an undated facility policy titled, Fit Testing Procedures-General Requirements, revealed, Policy Statement: The facility shall conduct fit testing per Occupational Safety and Health Administration Requirement. Procedures: 1. The facility will perform fit test on newly hired employee and annually thereafter and as needed for new supplies. In an interview on 02/08/2024 at 3:40 PM, Licensed Vocational Nurse #3 stated she has worked in the facility since 2021. LVN #3 stated she was last fit tested for a mask in 2020. In an interview on 02/08/2024 at 3:43 PM, Certified Nursing Assistant (CNA) #5 stated she has worked in the facility for seven months. CNA #5 stated she has never been fit tested for an N95 mask. In an interview on 02/08/2024 at 3:48 PM, Registered Nurse (RN) #4 stated she has worked at the facility for one year and had not been fit tested for a N95 mask. During an interview on 02/08/2024 at 3:52 PM, the Infection Preventionist (IP) stated the facility only had evidence of fit test being performed in 2020. The IP stated because the fit testing had not been updated, there was no guarantee the masks the facility had in stock would fit the staff members who worked with the COVID-19 positive residents. The IP stated the fit tests should be completed once a year. During an interview on 02/08/2024 at 4:08 PM, the Administrator stated the facility had not completed fit tests for staff as directed in their policy. During an interview on 02/08/2024 at 4:15 PM, the Director of Nursing (DON) stated fit testing for the staff was last completed in 2021. Per the DON, fit testing had not been completed for 2023. The DON stated fit tests should have been completed annually because it could affect the health condition of the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056495 If continuation sheet Page 6 of 6