Health inspection·May 28, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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 dioxide due to respiratory pump failure), acidosis (occurs when acid builds up or when bicarbonate (a base) is lost), and hyperkalemia (increase potassium levels in the blood). During a record review of Resident 2's admission record, he was admitted to the facility on [DATE] with diagnoses that included fracture of scapula (bone on the upper part of the back), and dysphagia (difficulty swallowing). During an observation on 5/28/25 at 9:45 am, the facility felt cold. Observed staff wearing down jackets, long sleeve shirts under scrub tops, zip up sweatshirts, and quilted jackets. During a concurrent observation and interview on 5/28/25 at 9:55 am, Administrative Assistant (AA) wore a wool shawl over her shoulders. AA stated facility is usually cold. AA stated facility temperature was controlled from a central location. AA confirmed thermostat in her office read 64 degrees F. During an interview with Assistant Director of Nursing (ADON) on 5/28/25 at 10:05 am, ADON stated facility was very cold in the morning. ADON stated facility got better as the outside temperature rose during the day and by evening, it's fine. ADON stated staff and residents all complained about how cold facility was, But we give them blankets. Page 1 of 2 555909 555909 05/28/2025 Colusa Medical Center - Snf 199 E Webster Street Colusa, CA 95932

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with Director of Maintenance on 5/28/25 at 10:15 am, DOM checked temperatures in hallway. Observed room [ROOM NUMBER] read 68 degrees F. Resident 1 stated This is the coldest hospital I've ever been in. I've been here since February! Observed Resident 1 covered with multiple blankets up to his chin. Observed Resident 1 with 20 feet of oxygen tubing via nasal cannula (a medial device used to deliver supplemental oxygen). Resident 1 stated he used oxygen via nasal cannula at all times. Resident 1 stated when room was cold, his tubing became stiff, and he could not ambulate to the bathroom easily because tubing was stiff and would not unroll. Resident 1 stated his room would often get so cold, his tubing would be hard, and he was afraid it would break or crack. Resident 1 stated he would not get out of bed, even if he needed to go to the bathroom because the floor was too cold. Resident 1 stated cold temperatures in room and building have affected his desire to ambulate. Resident 1 stated he told staff too many times, and their response was to bring extra blankets. Resident 1 stated even with extra blankets; he was cold. During an interview with DOM on 5/28/25 at 10:21 am, DOM confirmed residents and staff appeared to be cold since they were all wearing jackets. During an interview with DOM on 5/28/25 at 10:30 am, DOM stated facility temperature range should be 75 degrees F. DOM could not confirm what federal regulation was. DOM confirmed thermostats in facility read between 62-65 degrees F. DOM confirmed there was no consistent way to monitor what temperature reached the floor and the rooms. DOM stated thermostats were old and building was old. DOM confirmed staff and residents have complained about being cold. DOM confirmed he did not know what to do about it. DOM confirmed he did not try to figure out a solution. DOM stated he would speak to the company that handled the maintenance of the thermostats on how to proceed. During an interview with SEM on 5/28/25 at 10:40 am, SEM stated temperature range should be between 68-75 degrees F. SEM could not confirm what federal regulation was. SEM sated facility temperature had not been measured or logged for one year or more. SEM stated DOM had not checked temperatures. SEM confirmed facility felt chilly. SEM confirmed facility did not have a policy regarding temperature and resident comfort. SEM stated all facility policies were moved over to a new system and was not able to produce any maintenance policies. During an interview on 5/28/25 at 11:29 am, Resident 2 stated he was always cold. Resident 2 stated he had mentioned being cold to the staff so many times. Resident 2 stated staff response was to bring him extra blankets. Resident 2 stated he was still cold even with extra blankets. Resident 2 stated this affected his desire to get out of bed and ambulate outside of his room. During an interview with Director of Nursing on 5/28/25 at 11:40 am, DON stated she encouraged staff to put in maintenance tickets to DOM to fix facility cold temperature. DON stated DOM was supposed to monitor facility temperature. DON stated she had no idea what DOM would do to fix the issue. DON stated she mentioned cold temperature issue to facility administration and received no response. DON confirmed facility was cold. DON confirmed staff and residents have complained about facility being too cold. DON confirmed she did not know federal regulation for temperature and homelike environment. DON confirmed she did not know what to do to fix the issue. 555909 Page 2 of 2