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. (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 3 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 10/30/2024 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)