Colby Operator, LLC

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents, of which five were reviewed for sufficient and competent nurse staffing. Based on the record review and interview, the facility failed to verify one of the five Certified Nurse Aides (CNA) had a current license prior to employing her and allowing her to work the floor providing resident care.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents, with one reviewed for dignity and respect. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 3, who was left uncovered in bed with only an incontinence brief on. This placed R3 at risk for impaired dignity.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with resident-centered interventions for Activities of Daily Living (ADL) for one resident, resident (R) 25. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide consistent bathing and grooming for one resident, Resident (R) 25. This placed the resident at risk for complications related to poor hygiene and impaired dignity.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold insulin (medication that lowers the level of glucose [a type of sugar] in the blood) when the medication was out of the physician's ordered parameters for one resident, Resident (R) 3. This placed the resident at risk for adverse effects related to medication.

Inspectors wroteThe facility identified a census of 34 residents with three residents reviewed for pressure ulcers. The facility failed to identify and provide appropriate interventions consistent with the standards of care to prevent pressure ulcers from developing and worsening for Resident (R) 1. On 03/11/24, R1 developed two facility-acquired Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to her bilateral buttocks. On 05/16/24 the wound specialists identified diffuse pressure and redness to the entire intergluteal cleft (a deep groove that separates the buttocks and runs from the third or fourth sacral spine to the anus) area. [...]

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 33 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for food borne illness.

Inspectors wroteThe facility had a census of 33 residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit the information for Licensed Nurses (LN) 24 hour/day staffing as required. This placed the residents at risk for unidentified and ongoing inadequate staffing.

Inspectors wrote- On 09/26/23 at 07:55 AM, observation revealed R27 in the dining room. His oxygen tubing and cannula laid on the dining room floor. On 09/26/23 at 08:58 AM, observation revealed R27 self propelled his wheelchair into the television area, his oxygen tubing and cannula was wound around the right wheel of his wheelchair. Further observation revealed Administrative Staff B asked Administrative Nurse E to get R27 a new set of tubing sine R27's touched the ground. Administrative Nurse E replaced the old tubing and assisted R27 with the new tubing. Continued observation revealed, the oxygen tank R27 was using was empty and Adminsitrative Nurse E brought R27 a new tank. Administrative Nurse E obtained R27's oxygen saturation (percentage of oxygen in the blood) which was in the 70 percentile (normal is 90-100 %). [...]

Inspectors wroteThe facility had a census of 33 residents. Based on observation and interview, the facility failed to maintain an effective pest control program for the 33 resident's residing in the facility. This placed the resident's at risk for illness and an uncomfortable environment.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to adequately label and store insulin (hormone that lowers the level of glucose in the blood) for five residents in the facility's medication room. This placed the affected residents at risk for ineffective medication regimens.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with two reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 14 remained free from neglect when the facility failed to provide the necessary care and service as directed by the resident's plan of care, on more than one occasion, despite being aware of what care the resident required. This placed the resident at risk for congoing neglect and related complications.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R)16 and R18 for posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed R16 and R18 at risk for unmet care needs.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to revise Resident (R) 28's plan of care to reflect his current needs and use of a mechanical lift for transfers. This placed the residents at risk for preventable accidents and injury due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on record review, and interview, the facility failed to complete a discharge summary, a reconciliation (summary) of pre and post discharge medications, and post-discharge plan of care for Resident (R) 30, who discharged from the facility. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to provide an environment free from preventable accidents and falls for Resident (R)9, R14, and R20. This placed the residents at risk for further falls and injury.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with four reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27, who required continuous supplemental oxygen, received adequate respiratory care and services. This placed the resident at risk for physical decline.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 16 and R18 received trauma informed care to eliminate or mitigate triggers that may care re-traumatization which placed the residents at risk for unmet behavioral health care needs and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from significant medication errors when medication was not administered per physician orders for Resident (R) 81. This placed the resident at risk for decreased physical and mental well-being.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation and interview, the facility failed to display current daily nursing staffing hours as required.

Inspectors wroteThe facility had a census of 27 residents. Based on observation, record review, and interview the facility failed to provide a backflow device (unwanted flow of water in the reverse direction) or a two-inch air gap for the drainage system of the kitchen ice machine, used by the 27 residents who resided in the facility. This placed the affected residents at risk to receive contaminated ice. Findings Included: - On 05/11/22 at 11:26 AM, observation revealed a two-inch plastic drainpipe extended from the back of the ice machine approximately 10 feet and inserted into a floor drain under a cabinet. Continued observation revealed the ice machine drainage system had no backflow device or two-inch air gap at the floor drain. [...]

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents of which one was reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions for respiratory assessment and care of respiratory equipment for Resident (R) 24, who required oxygen and nebulizer treatments (device which changes liquid medication into a mist easily inhaled into the lungs). This placed R24 at risk for miscommunication related to respiratory cares.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents, with one reviewed for urinary catheter. Based on observation, record review, and interview, the facility failed to maintain appropriate handling of urinary catheter tubing to ensure safe positioning and avoid contact with the floor for one sampled resident, Resident (R) 17. This placed the resident at risk for the catheter tube kinking, dislodging, and urinary tract infections (UTIs).

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide appropriate respiratory care and services for Resident (R) 24 who required oxygen and nebulizer treatments. This placed R24 at risk for infection and respiratory complications.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents and two closed record residents. Based on record review, and interview the facility failed to ensure the availability of physician ordered pain medication for one of 14 sampled residents, Resident (R) 30. This placed R30 at risk for untreated pain.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 21's, R22 and R25's insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened, on one of two medication carts. This placed these residents at risk for ineffective medications.