Colfax General LTC

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food was stored appropriately and not left open to air in the kitchen freezer. These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 04/21/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards for 3 (R # 5, 6, and 7) of 9 (R #1, 5, 6, 7, 8, 9, 10, 11, and 12) residents when staff failed to: 1. Ensure R #5's, R #6's, and R #7's humidity (attachable bottle to moisten administered oxygen) is added to concentrator and that O2 concentrator is capable of having humidy added. 2. Label and date oxygen (O2) tubing per physician orders for R #5, R #6 and R #7. If the facility is not following physician orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident's provider of a decline in condition for 1 (R #1) of 1(R #1) resident reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider when the resident experiences a change of condition, then the provider is unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on observation and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 1 (R #13) of 5 (R #2, #3, #4, #5, and #13) residents observed for call lights. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Kitchen refrigerators were free from dietary staff personal food. 3. Food was stored appropriately and not left open to air in the kitchen. 4. Salad was stored on ice prior to meal service. These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 01/27/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation and interview, the facility failed to ensure that all garbage and refuse containers have lids or are otherwise covered in the kitchen. This deficient practice could likely affect all 32 residents identified on the resident census list provided by the Administrator on 01/27/25. This deficient practice could likely result in shelter and feeding of pests.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #34) of 1 (R #34) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially life saving procedures.

Inspectors wroteBased on record review and interview, the facility failed to report the results of an investigation regarding allegations of abuse for 2 (R #'s 8 and 22 ) of 2(R #'s 8 and 22) residents reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency (SA), then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days, for an allegation of abuse for 2 (R #'s 8 and 22) of 2 (R #'s 8 and 22) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on observation and interview, the facility failed to assure medications and other medical supplies were properly stored and not expired. This deficient practice had the potential to affect all 28 residents identified on the facility census list provided by the Director of Nursing (DON) on 01/16/24. Improperly stored medications and medical supplies could likely lead to confusion and possibly result in residents being administered expired medications and supplies.

Inspectors wroteBased on an interview the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality, if the c ourse study includes food service or restaurant management, from an accredited institution of higher learning; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety. This deficient practice is likely to affect all 28 residents identified on the resident census list provided by the Director of Nursing (DON) on 01/16/24. These deficient practices are likely to expose residents to food borne illnesses.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that 1 (R #30) of 1 (R #30) resident reviewed was receiving the necessary behavioral health care services to meet the residents needs. This deficient practice likely resulted in resident not getting the care and assistance he needed, resulting in R #30 assaulting a staff member and being transferred to jail.

Inspectors wroteBased on observation and interview, the facility failed to store foods under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer are properly covered. 3. Ensuring used oil was covered appropriately, labeled, and dated in the dry storage. These deficient practices are likely to affect all 26 residents listed on the resident census list provided by the Director of Nursing (DON) on 02/17/23, and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on record review and interview, the facility failed to have a qualified, trained, or appropriately certified Infection Control Nurse designated as the Infection Preventionist (IP) affecting all 26 residents identified on the resident census list provided by the Director of Nursing (DON) on 02/27/23. This deficient practice is likely to result in residents being at greater risk of infectious disease.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure narcotic medications (regulate medications-perception-altering or sensory-dulling medications) are properly documented after medication administration. 2. Ensure medication storage room is kept at the appropriate temperature (68-77 degrees Fahrenheit) These deficient practices are likely to negatively impact the health of all 26 residents listed on the census provided by the Director of Nursing (DON) on 02/27/23. A. [...]

Inspectors wroteBased on interview the facility failed to submit accurate direct care staffing information to CMS (Centers for Medicare Services). This deficient practice is likely to result in inaccurate direct care staffing information for residents/facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #27) of 1 (R #27) residents reviewed for Minimum Data Set (MDS) assessments, had MDS documents completed, submitted and finalized in a timely manner (after her discharge). If MDS assessments are not completed and submitted in a timely manner, then residents are likely to receive less than optimal care.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that reflects anticoagulant use (medication used to prevent blood clots) for 1 (R #8) of 1 (R #8) residents reviewed. Failure to develop and implement a resident centered care plan may result in staff's inability to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive.

Inspectors wroteBased on record review and interview the facility failed to ensure the attending physicians reviewed and responded to pharmacy recommendations for 6 residents [R #2, 9, 10, 12, 14, 16] of 7 residents [R #2, 8, 9, 10, 12, 14, 16] reviewed for Gradual Dose Reductions. If consultant pharmacist recommendations are not reviewed by physicians and orders are not implemented on time, residents are likely to continue taking medications they do not need, or potentially experience unnecessary drug interactions or adverse side effects. The findings for R #2: A. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations: On 05/19/22 pharmacist's recommendation for R #2 stated Please review Lorazepam [used to treat anxiety disorders] therapy for Gradual Dose Reduction (GDR). [...]