Health inspection·October 30, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure services for one of four sampled residents (Resident 1) when medication was administered by a Certified Nursing Assistant (CNA 1) to Resident 1 (RES 1). Residents Affected - Few This failure had the potential for harm when staff who are not trained to administer medications, administered medication outside of their scope of practice and job duties, which could cause medication errors. Findings: RES 1 was admitted to the facility in 2021 with diagnoses that included chronic pain (pain that lasts longer than 3 months) and morbid obesity (severe excess weight). Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24 indicated the Brief Interview for Mental Status (BIMS) scored 13, meaning Resident 1 was cognitively intact. During a review of RES 1's Order Summary Report dated 9/23/24, the orders indicated lidocaine patch for the treatment of pain 4% (%, a percentage of medication) apply to both knees, shoulders, and back for 12 hours on and 12 hours off. During a concurrent observation and interview on 10/30/24 at 10:12 a.m., a lidocaine patch was observed on the resident's bedside table with Certified Nurse Assistant 1 (CNA 1) in the room. RES 1 stated, CNAs place my [lidocaine] patches on . During an interview on 10/30/24 at 10:20 a.m., CNA 1 stated, .I sometimes put her lidocaine patches on for her. During an interview on 10/30/24 at 10:51 a.m., Licensed Nurse (LN 1) stated CNAs are not allowed to apply lidocaine patches. Only topical creams . During an interview on 10/30/24 at 11:31 a.m. with LN 2, LN 2 stated, The CNA does put patches on sometimes. They are not really supposed to. I leave it with the CNA because she is not ready and they are cleaning her up. Then he applies it after. During an interview on 10/30/24 at 12:14 p.m. with CNA 4, CNA 4 stated, CNAs do not place lidocaine patches on patients, Nurses do that. During an interview on 10/30/24 at 12:14 p.m. with the DON, the DON stated that nurses are supposed to administer lidocaine patches, not the CNAs. Page 1 of 3 056495 056495 10/30/2024 Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy titled, Medication Administration dated 4/2019 indicated that, Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The facility's CNA job description titled, Certified Nursing Assistant Competency Assessment dated 10/2020, indicated that CNAs are to provide non-pharmacological interventions for pain in accordance with the plan of care. 056495 Page 2 of 3 056495 10/30/2024 Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to ensure a safe and functional living environment for when two of four sampled residents (Resident 1 & Resident 3) had sliding glass doors in their rooms that were not able to be locked. This failure had the potential for people to enter the room from outside of the building and resulted in Resident 1 feeling unsafe. Findings: Resident 1 (RES 1) was admitted to the facility in 2021 with diagnoses that included depression. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24 indicated the Brief Interview for Mental Status (BIMS, a test of cognition) scored 13, meaning Resident 1 was cognitively intact. During an interview on 10/30/24 at 10:26 a.m., RES 1 stated that her sliding glass door does not lock and she has been asking for it to be fixed. During an observation on 10/30/24 at 10: 27 a.m., the Department was unable to lock the sliding glass door in RES 1's room. During a concurrent observation and interview on 10/30/24 at 10:35 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 was observed attempting to lock the sliding glass door in RES 1's room and was unable to lock it. He stated, It is supposed to lock. We will let maintenance know. Residents have access to outside, so someone could possibly walk in here. During an interview on 10/30/24 at 10:48 a.m., RES 1 stated, It makes me feel unsafe. The lock hasn't worked for three years. I keep asking and it never gets fixed. I hear people talking out there sometimes and it scares me. During an observation on 10/30/24 at 11:45 a.m., the sliding glass door did not lock in RES 3's room. During an observation and interview on 10/30/24 at 11:46 a.m., CNA 3 was observed attempting to lock sliding glass door in RES 3's room and was unable to lock it. CNA 3 stated, It's broke. Can't lock it. It is a safety issue. Someone can walk in. During an interview on 10/30/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated that she was unaware of doors not locking in the facility and will let maintenance know. She also confirmed that doors not locking is a safety concerns because people can enter the room from outside and other residents can access the rooms. The facility's policy titled, Maintenance Service, dated 12/2009, states, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 056495 Page 3 of 3