Health inspection·March 6, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments according to physician orders for one of three sampled residents (Resident 1) when Resident 1 was not given multiple treatment medications as ordered by the physician in November 2023, December 2023, and January 2024. Residents Affected - Few This failure increased the resident's potential to have unmet health needs. Findings: Review of an admission Record, indicated Resident 1 was admitted to the facility in 2022 with diagnoses including kidney disease and diabetes. Review of Resident 1's Minimum Data Set [MDS, an assessment tool], dated 1/14/24, indicated Resident 1 had no memory issues or behaviors. A review of Resident 1's clinical record included the following documents: --A Treatment Administration Record (TAR), dated 11/23, indicated clobetasol propionate cream (a dermatitis medication) was not administered on the evening shift on 11/16/23. --The treatment to apply house barrier cream (a medication to prevent skin break down) to buttocks, coccyx, sacrum, groin, and peri area was not administered on the evening shift on 11/14/24. --Also, the order of miconazole powder (an antifungal medication) was not administered on the night shift on 11/17/24 and evening shift on 11/14/24. --A TAR, dated 12/23, indicated the clobetasol propionate cream was left blank and not administered on the evening shift on 12/1/23 through 12/3/23 and on the day shift on 12/6/23. --Also, the house barrier cream to buttocks, coccyx, sacrum, groin, and peri area was not administered on the evening shift on 12/22/23. --Furthermore, the order of miconazole powder was not administered on the evening shift on 12/22/23. A TAR, dated 1/24, indicated the clobetasol propionate cream was left blank and not administered on the day shift on 1/5/24. Page 1 of 3 056495 056495 03/06/2024 Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670

F 0684 A Census List, dated 3/6/24, indicated Resident 1 was in the hospital from [DATE] to 2/2/24. Level of Harm - Minimal harm or potential for actual harm During an onsite observation on 2/20/24 at 11:45 a.m., Resident 1 was not in the facility. Residents Affected - Few During a concurrent interview and record review on 2/20/24 at 1:53 p.m., the Director of Nursing (DON) confirmed the blank spot in the TAR indicated the order was not completed and was not done according to physicians orders. A review of the facility's policy titled, Administering Medications, revised 4/19, stipulated, Medications are administered in a safe and timely manner, and as prescribed. A review of the facility's policy titled, Charting Errors and/or Omissions, revised 12/2006, stipulated, Accurate medical records shall be maintained by this facility. 056495 Page 2 of 3 056495 03/06/2024 Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 118 when the medication cart and treatment cart were left unlocked and unattended. These failures had the potential for medication misuse and drug diversion. Findings: During a concurrent observation and interview on 2/20/24 at 11:45 a.m. with Licensed Nurse 1 (LN 1), medication cart 1 in a hallway was unlocked and left unattended. The nurse was not in the hallway. There were residents and other staff in the hallway. LN 1 confirmed the medication cart was not locked and should have been locked. During a concurrent observation and interview on 2/20/24 at 1:50 p.m., the treatment cart was unlocked and unattended in the hallway. There were other staff walking in the hallway. The nurse was inside a resident room performing a dressing change. LN 2 confirmed the treatment cart was unlocked and unattended and should have been locked. During an interview on 2/20/24 at 1:53 p.m., the Director of Nursing (DON) confirmed the medication cart and treatment cart should have been locked. Review of the facility's policy titled, Storage of Medications, dated 2001, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Review of the facility's policy titled, Security of Medication Cart, 4/2007, indicated, The medication cart shall be secured during medication passes. 056495 Page 3 of 3