Colusa Medical Center - SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a homelike environment for two of three sampled residents (Resident 1 and Resident 2) when it failed to maintain facility temperature above 71 degrees Fahrenheit (F). This failure resulted in Resident 1 and Resident 2's decreased desire to ambulate out of bed, Resident 1's oxygen tubing became stiff, and every day-shift staff member wore a padded jacket or sweatshirt during their shift. Findings: During a record review of facility policies, Safety and Emergency Management (SEM) stated facility policies were moved to a digitalized form and could not be produced during the investigation. During a record review of Resident 1's admission record, he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation (COPD - a condition caused by damage to the airways or other parts of the lung), acute respiratory failure with hypercapnia (an increase in arterial carbon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure they had a Registered Nurse (RN) 8 hours a day, 7 days per week from 4/1/24 to 12/28/24. This failure had potential to affect the quality of care and quality of life of residents and put them at risk for injury by not having an RN to oversee their care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 3: (April - December 2024), indicated the facility had no RN on duty for: 4/21/24, 4/27/24, 4/28/24, 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/18/24, 5/19/24, 5/25/24, 5/26/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, 6/16/24, 6/22/24, 6/23/24, 6/29/24, 6/30/24, 7/6/24, 7/7/24, 7/13/24, 7/14/24, 7/20/24, 7/21/24, 7/27/24, 7/28/24, 8/3/24, 8/4/24, 8/10/24, 8/11/24, 8/17/24, 8/18/24, 8/24/24, 8/25/24, 8/31/24, 9/1/24, 9/7/24, 9/8/24, 9/14/24, 9/15/24, 9/28/24, 9/29/24, 10/5/24, 10/6/24, 10/12/24, 10/13/24, 10/19/24, 10/20/24, 10/26/24, 10/27/24, 11/2/24, 11/3/24, 11/9/24, 11/10/24, 11/16/24, 11/17/24, 11/23/24, 11/24/24, 11/30/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop personalized Activity care plans for four of five residents who were sampled for care plans. (Residents 4, 5, 59, and 110) This had the potential for the residents' activity interests to go unmet and cause them boredom and depression which could negatively impact their rehabilitation goals and psychosocial well-being. Findings: A review of the facility's policy titled, Activity Program revised 4/2024, indicated, The Skilled Nursing Program provides an ongoing program of meaningful activities appropriate to the needs and interests of residents and is an integral part of the resident's overall plan of care. The activities program is staffed and equipped to encourage the participation of each patient, to meet the needs and interest of each patient .2. Each Resident's activity program is implemented for each patient and shall be integrated with the individual interdisiciplinary [involving all care areas] patient care plan. A review of Resident 4's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS). The failure to submit the required data, staffing hours and census information, can prevent determining an adequate level of staff is working at a given time, leading to inadequate care of residents and adverse clinical outcomes. Findings: On 03/19/24 at 8:30 AM, the PBJ reporting was reviewed with the Interim Facility Administrator (IFA). IFA stated, I am not sure who is doing it. I would have to check and see who it is here. On 3/19/24 at 9:30 AM, during an interview with the Director of Quality (DQ), the DQ sated, We had something come in about submitting PBJ Data and I looked it over and told them it wasn't something I do in quality. I don't know what they did with it from there. The DQ was asked who would be submitting the data and she replied, I don't know who they gave it to, possibly the DON? On 3/19/24 at 10:00 AM, the Assistant Director of Nursing (ADON) provided staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain a clean and sanitary environment in the medication room at nursing station B, when an overhead air intake duct vent cover was notably fuzzy and dark with dusty material and particulates. This failure had the potential to contaminate (contact with an unclean substance which renders something unusable), medications administered to residents with a potential for poor health outcomes. Findings: A concurrent observation and interview, was conducted on 3/19/24 at 1:45 pm, in the medication room at nursing station B with Charge Nurse (CN) 1. An overhead air intake duct vent cover was notably fuzzy and dark with dusty material and particulates, CN 1 stated, Oh, it needs to be cleaned. A concurrent interview and record review was conducted on 3/20/24 at 2:15 pm, with the Director of Pharmacy (DP) who confirmed that medications being pulled out from the automated medication dispenser could be contaminated by dirty air flow.

Based on observation, interview and record review, the facility failed to maintain temperature logs for the resident food/snack refrigerator. The failure to monitor refrigerator temperatures can lead to food borne illness by food that has unknowingly not been maintained at a safe temperature. Findings: On 03/19/24 at 2:24 PM, during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, the Nurses Station B Resident/Patient refrigerator was observed. The refrigerator is a split, over under refrigerator/freezer unit with separate doors for each compartment. LVN 3 located and read the thermometer temperatures aloud. The refrigerator was 36 degrees Fahrenheit and 18 degrees Fahrenheit in the freezer. A log sheet was in a clear plastic sleeve affixed to the left side of the refrigerator. The sleeve contained monthly temperature log sheets upon which staff document daily refrigerator/freezer temperatures. LVN 3 confirmed the temperature sheets for the refrigerator/freezer were not filled out by staff for January, February and up to March 19, 2024. LVN 3 stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure the attending pharmacist Medication Regimen Review (MRR) were documented in five of five resident's (Resident 109, 4, 7, 2 and 3) medical record. This did not follow facility policy. Findings: A review of the facility's policy titled: Psychotherapeutic Drug Management reviewed on September 2021, the policy indicated that The facility pharmacist shall note in the resident's medical record that the pharmacy medication review regimen was completed. The policy continues to indicate that all documentation shall be included in the medical record. During Resident medical record reviews on 11/2/2021, five resident's medical records were reviewed and there were no pharmacist medication review's recorded in their medical record. During an interview on 11/2/2021, at 12:30 PM, with the Director of Nursing (DON), she indicated that the medication review was done by the pharmacist. She indicated that the medication review records, by the Pharmacist, are kept on his computer and not in the resident's medical records. No one had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure five of five residents (Resident 2, 3, 4, 7, 109) had completed comprehensive care plans to meet the needs of the residents when: 1. Resident 4 did not have a bowel and bladder care plan; 2. Resident 2, 4, and 7's did not have discharge care plans; and 3. Resident 2, 3, 4, 7, and 109, did not have activity care plans. These failure had the potential to negatively effect the physical and psychosocial needs of these residents and prevent them from achieving their goals. During a review of the facility's policy titled Care Plans dated June 2019, the policy indicated, A comprehensive care plan is developed for the resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. 4. The care plan: a. addresses the resident's needs, strengths, and preferences identified in the comprehensive assessment; b. Addressees risk factors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and policy review the facility failed to provide two of five Residents (Resident 7 and 4), the right to be treated with dignity and respect and provide privacy during their treatment and care of personal needs. This failure had the potential for Resident 7 and Resident 4 to feel a lack of self-esteem and self-worth. Findings: A review of the facility's policy titled Resident Rights, dated November 2017, indicated that patient rights were 12. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. During an observation on 11/01/21, at 10:49 AM, in the facility hallway, Resident 7 was in her wheel chair (w/c) being wheeled by the therapy staff. Resident 7 had a Foley catheter drainage bag, with urine in it, hanging on the w/c. The drainage bag was in full view of visitors and staff who were in the hallway. During an observation and interview on 11/02/21, at 9:40 AM , in the facility hallway, Resident 4 was being wheeled in a shower chair, to the shower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to maintain a safe clean and comfortable homelike environment when it: 1. Did not maintain a resident room above 68 degrees as required by regulation and; 2. Maintain a kitchen drain that allowed water to puddle on the dishwashing room floor. These failures could lead to residents and visitors being uncomfortable, loss of body heat and slip and fall injuries. Findings: 1. On 11/03/2021 at 9:25 AM, during a concurrent observation and interview, Resident 109 was observed sitting on her bedside with a blanket wrapped around her shoulders and being held closed with her left hand. Resident 109 was asked about the room temperature and wearing the blanket. Resident 109 affirmed the room is cold and she was wearing the blanket to stay warm. The room temperature at Resident 109's bed was checked with a handheld thermometer. Resident 109 was asked to read the temperature and she replied, 67.5. The temperature was visually confirmed at 67.5 degrees Fahrenheit. It was observed there was no thermostat on the wall. Resident 109's roommate,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure the medication error rate did not exceed five percent or greater when there were 25 medication pass opportunities for error and two errors resulting in a medication error rate of eight percent. This failure resulted in the medication error for two of five residents (Resident 2 and Resident 109) when 1. Resident 2's medication were combined, and 2. The manufacture instructions were not followed when medication was given to Resident 109. These errors had the potential to cause altered therapeutic doses of medications. Findings: 1. During observations and interview on 11/01/2021, at 2:10 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared medications, Buspirone 7.5 mg (milligrams) (anxiety medication) and Tylenol 325 mg two tablets (pain medication). She crushed the medications together and combined them in a medication cup and added water to dilute the medications. LVN 1 went to Resident 2's room to dispense the medications. Resident 2 had a gastrostomy tube (G-Tube, A tube placed through the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility did not employ industry standards as required in the storage of dry goods. Not employing industry standards could lead to the spread of food borne illness to residents leading to illness and adverse clinical outcomes. Findings: On 11/01/2021 at 11:51 AM the Kitchen was toured with the Dietary Service Supervisor (DSS). While observing the dry food storage area three items were found to be open and did not have expiration/discard dates as required by facility policy. The items were: Pancake Mix- received August 21, 2021; Pancake Mix- received October 21 (Not fully dated as to when received) and; Corn Starch- received August 8, 21. The three packages were opened however, staff did not write the date of opening on the package. Due to no opened date staff would not know when the items were stale, unusable or needing to be discarded because of age. The DSS acknowledged the dates were supposed to have been added by staff at the time of opening per policy and were not. The DSS also pointed out a document of expiration timeframes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility does not have the necessary membership attendance at the Quality Assurance/Performance improvement meetings as regulations require. The failure to have membership attendance as required reduces the exchange of information between disciplines decreasing the effectiveness of the provision of quality care leading to suboptimal care and outcomes. Findings: The Director of Quality Management (QM) was interviewed on 11/04/2021 at 10:15 AM regarding the Quality Assurance/Performance Improvement (QAPI) at the facility. The QM provided and reviewed signed attendance sheets titled, Quality Improvement Committee (QIC) Confidentiality Statement. The Medical Director did not affirm his attendance by signing attendance sheets for May 14, 2021 and August 30, 2021. When discussing the attendance by the Medical Director the QM stated, I know it is required. I just can't get him to come. The QM was asked for a facility policy or procedure for attendance at the QIC meetings. The QM provided and reviewed the document titled, Quality Management Plan. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to ensure infection control measures were adhered to when three of three staff (Certified Nursing Assistant [CNA] 1, Licensed vocational Nurse [LVN] 1, and LVN 2) provided patient care without following infection control policy and procedures. These failures had the potential to cause the spread of infection and disease to the residents they cared for. Findings: 1. During a concurrent interview and observation on 11/1/2021, at 11:39 AM, CNA 1 was observed assisting Resident 4 with toileting. CNA 1 used a standing lift (a device that assists residents to stand) to stand Resident 4 up. With gloves on, CNA 1 removed the soiled brief. There was a moderate amount of stool and urine on Resident 4 and in the brief. CNA 1 cleaned the Resident from front to back with wipes. She threw away the soiled brief and wipes but kept her soiled gloves on. With those same soiled gloves, CNA 1 put a clean brief on Resident 4, removed the sling that was around his waist, touched Resident 4's bedside table and moved it in front of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.