Health inspection·March 21, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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, the logs are not filled out like they are supposed to be. They are supposed to do it every day and they haven't. On 3/19/24 at 3:00 PM, The Director of Quality (DQ), viewed the incomplete staff documentation on the temperature log sheets. The DQ stated, there are a lot of missing entries. On 3/20/24 at 2:30 PM, the DQ provided copies of the facility refrigerator policies. The DQ provided a policy titled, Food Storage which states, Records of refrigerator and freezer temperatures are to be kept for ninety days (or per state requirements). No policy direction was given as to which staff are to complete a temperature log. . Page 1 of 3 555909 555909 03/21/2024 Colusa Medical Center - Snf 199 E Webster Street Colusa, CA 95932

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. 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 work schedules for the week of the survey. The ADON stated, I don't know who does the PBJ data. The ADON did not have any PBJ data available to her. On 3/20/24 at 10:15 AM, the DON was interviewed. The DON could not produce any information regarding any PBJ reporting. The DON stated, PBJ data, I don't know about that. Nobody is doing it that I know of. . 555909 Page 2 of 3 555909 03/21/2024 Colusa Medical Center - Snf 199 E Webster Street Colusa, CA 95932

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 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. 555909 Page 3 of 3