Colusa Medical Center - SNF

In the surveyor’s words

From the most serious findings on record at Colusa Medical Center - SNF, in the surveyor’s own words.

• Actual harm, isolatedF690Oct 5, 2021

  Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was admitted with an indwelling catheter (tube inserted into the bladder to drain urine) received appropriate care and services to prevent and promptly treat urinary tract infection ([CONDITION(S)], an infection involving any part of the urinary system, including urethra, bladder, ureters and kidney) as indicated in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. The facility did not document Resident 1's urine color, character and output. 2. The facility did not follow up with laboratory testing of foul-smelling urine reported by Resident 1 on [DATE]. 3. […]

• No harm, potential for more than minimal, widespreadF727Apr 4, 2025

  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,… […]

• No harm, potential for more than minimal, widespreadF851Mar 21, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF756Nov 4, 2021

  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. […]

• No harm, potential for more than minimal, patternF584May 28, 2025

  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. […]