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Deficiency Records for Colusa Medical Center - Snf
A list of the most recent deficiencies for Colusa Medical Center - Snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Colusa Medical Center - Snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-03-28 | 2024-04-25 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-03-21 | 2024-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-21 | 2024-04-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-21 | 2024-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-04 | 2021-12-02 | N |
| 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. | Health | 2021-11-04 | 2021-12-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-04 | 2021-12-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-04 | 2021-12-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-04 | 2021-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2021-12-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-11-04 | 2021-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-12-02 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-11-04 | 2021-12-02 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-10 | 2021-12-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-10 | 2021-12-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-10 | 2021-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-10 | 2021-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-10 | 2021-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-10 | 2021-12-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-22 | 2019-08-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-05-22 | 2019-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-22 | 2019-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-22 | 2019-08-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-22 | 2019-08-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-22 | 2019-08-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-05-22 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-22 | 2019-08-13 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-22 | 2019-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-22 | 2019-08-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-22 | 2019-08-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-22 | 2019-08-05 | N |
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