Health inspection·April 4, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 admission record indicated he was admitted on [DATE] with diagnoses that included cellulitis (an infection). A review of Resident 4's care plans reflected there had been no individualized care plan developed which described his activity interests. A review of Resident 5's admission record indicated he was admitted on [DATE] with diagnoses that included a broken left shoulder. A review of Resident 5's care plans reflected there had been no individualized care plan developed which described his activity interests. A review of Resident 59's admission record indicated she was admitted on [DATE] with diagnoses that included heart failure. A review of Resident 59's care plans reflected there had been no individualized care plan developed which described her activity interests. A review of Resident 110's admission record indicated she was admitted on [DATE] with diagnoses that included kidney disease. Page 1 of 3 555909 555909 04/04/2025 Colusa Medical Center - Snf 199 E Webster Street Colusa, CA 95932

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 110's care plans reflected there had been no individualized care plan developed which described her activity interests. In an interview on 4/01/25 at 1:20 PM, Activities Director (AD) stated that she interviews residents once a week to conduct assessments of their preferred activity preferences and documents the information in another computer system and not on the residents' actual care plan. In an interview on 4/3/25 at 1:30 PM, the Director of Nursing (DON) confirmed that by using two separate computer programs for activity documentation and care planning resulted in Resident's 4, 5, 59 and 110 not having individualized activity interest care plans developed. 555909 Page 2 of 3 555909 04/04/2025 Colusa Medical Center - Snf 199 E Webster Street Colusa, CA 95932

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 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. Residents Affected - Many 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, 12/1/24, 12/7/24, 12/8/24, 12/14/24, 12/15/24, 12/21/24, 12/11/24, 12/28/24, 12/29/24. In an interview and concurrent record review of PBJ staffing on 4/3/25 at 9:36 AM, Director of Nursing (DON) confirmed that there was not a dedicated RN 8 hours per day, 7 days per week, and on weekends to oversee the care of the residents in the facility. 555909 Page 3 of 3