Colfax Nursing and Rehab, LLC

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents received housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident (#3) was free of chemical restraints by failing to:1. assess the resident prior to administering a chemical restraint for potential underlying causes of the resident's behavior,2. attempt a less restrictive alternative for the resident's behavior, and3. assess the resident after the chemical restraint was administered. This deficient practice was identified for 1(#3) of 3 sampled residents. The facility's total census was 81.

Inspectors wroteBased on interview and record review the facility failed to ensure resident assessments were completed accurately for 1 (Resident #1) of 3 residents sampled.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents sampled with behavioral health diagnoses by failing to:1. Develop and implement a person-centered plan of care that addressed Resident #1's refusals of care including adherence to prescribed medication regimen;2. Ensure Resident #1's drug regimen remained free from an antipsychotic prescribed for undiagnosed Schizophrenia;3. Ensure Resident #1 had accurate monitoring of behaviors; and4. Notify the Psychiatric NP of Resident #1's refusals/non-adherence to prescribed medication regimen.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to adequately monitor a resident's behaviors related to his psychotropic medication use for 1 (#3) of 3 sampled residents. The facility's census was 81.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 4 (#5, #7, #12, #38) of 5 (#5, #7, #8, #12, and #38) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction.

Inspectors wroteBased on observation and interview the facility failed to ensure nurse staffing data requirements were completed and posted appropriately. This deficient practice had the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide drinks, including water, consistent with resident needs and preferences. The facility failed to ensure staff, in the dining room, provided water to 32 residents with their meal during lunchtime.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 74 residents who resided in the facility. The facility failed to ensure:1. Kitchen staff did not handle food with dirty gloves during food preparation; and 2. Kitchen staff wore beard restraints to prevent hair from contacting food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of infectious communicable diseases. The facility failed to ensure the following:1. Staff adhere to Enhanced Barrier Precautions (EBP) for Resident #4. 2. Staff follow the chemical manufacturer's dwell-time guidelines for proper sanitation. The total sample size was 43 residents. Review of the facility's undated policy titled, Enhanced Barrier Precautions revealed in part. Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multidrug-resistant organisms (MDRO's) to residents. EBPs employ targeted gown and glove use during high-contact care activities. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program by having multiple flies in several areas of the facility including residents' rooms, dining room, and kitchen. There were 74 residents who resided in the facility according to the facility's census.

Inspectors wroteBased on observations and interviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life by failing to ensure residents sitting at dining room table were served together at the same time during mealtime. This deficient practice had the potential to affect all Residents that used the facility's dining room during mealtime.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received a reasonable accommodation of their needs by failing to ensure the call light was accessible to a resident for 1 (Resident #32) of 43 sampled residents. Review of the facility policy titled, Call System, Residents, dated September 2022, revealed in part. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor. Review of Resident #32's demographic record revealed an admission date of 12/02/2021 with diagnoses that included in part. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order was implemented as required in the person centered plan of care for 1 (Resident #64) of 43 sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all care and services were provided according to accepted professional standards of clinical practice. The facility failed to ensure proper physician orders were obtained for Resident #30's oxygen therapy requirements. Total sample size was 43 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents while smoking for 1 (#34) of 1 Residents reviewed for smoking in a total sample of 43 Residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment was stored properly for 1 (Resident #30) of 1 residents reviewed for respiratory care. The total sample size was 43 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administration of medications to meet the needs of each resident for 1 (Hall X) of 2 (Hall X and Hall Z) medication carts reviewed for narcotic reconciliation.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure each resident's environment remained free of accident hazards. The facility failed to ensure hot water temperatures did not exceed 120 degrees for 15 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]., room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 28 resident rooms.

Inspectors wroteBased on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor resident's right to have access to the facility patio area outside of smoking times for 3 (#2, #3, and #R1) of 4 (#1, #2, #3, and #R1) sampled resident.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary and comfortable homelike environment for all residents in the facility by failing to ensure the facility was free of odor. The facility census was 73.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (#4) of 5 (#1, #2, #3, #4, and #5) sampled residents. The facility failed to: 1. Ensure S3 CNA and S4 CNA reported Resident #5's aggressive behaviors, and increased agitation to the nurse; and 2. Ensure Resident #4 was not physically abused by Resident #5.

Inspectors wroteBased on observations and interviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life by failing to ensure residents sitting at dining room tables were served together during mealtime. This deficient practice had the potential to affect any residents that use the facility's dining room during mealtime.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents received housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from sexual abuse by another resident, for 1 (Resident #33) of 1 resident reviewed for abuse, in a total sample size of 38.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a person-centered care plan for each resident by failing to: 1. Develop and implement a care plan for Resident #59 related to depression, and 2. Record food intake for and notify Resident #26's physician and family of significant weight loss. There were 38 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide baths, shaving, and nail care to dependent residents for 5 (#6, #10, #12, #66,and #87) of 7 (#6, #10, #12, #33, #44, #66, and #87) residents reviewed for ADL's.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu to ensure nutritional adequacy.

Inspectors wroteBased on interview and record review the facility failed to ensure pureed foods were prepared according to the approved recipe by methods which conserved nutritional value for 8 residents that are served pureed diets by the facility's kitchen.

Inspectors wroteBased observation, record review, and interview the facility failed to ensure residents received meals at regular times, comparable to normal meal times in the community and in accordance with residents' needs and preferences. This deficient practice had the potential to affect all residents who are served meals in the dining room.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Freezer and refrigerator temperatures were monitored; 2. Sanitation levels were checked in the 3 compartment sink; 3. Refrigerated food contents were labeled, dated, and stored in a sanitary manner; and 4. Kitchen equipment was clean and sanitary.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 84 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#21 and #44) of 3 (#21, #44, & #240) sampled residents for Advanced Beneficiary Notice of Non-Coverage (ABN).

Inspectors wroteFACILITY Based on record review and interview, the facility failed to ensure a quarterly assessment was completed timely for 1 (#51) of 1 resident reviewed for Resident Assessments. There were 84 residents in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (#23 and #30) of 38 sampled residents. The facility failed to ensure: 1. Physician's orders for referring Resident #30 to a dermatologist were followed, and 2. Abnormal lab resullts were reported to provider and urine sample was recollected for Resident #23.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#87) of 2 (#40, and #87) sampled residents for respiratory care. The facility failed to ensure Resident #87 had a physician's order to receive oxygen therapy.

Inspectors wroteBased on record review and interview, the facility failed to include the Medical Director or his designee in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 84.

Inspectors wroteBased on observations and interviews the facility failed to ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall Y) of 3 (Hall X, Hall Y, and Hall Z) hallways observed in the building. This had to potential to affect 24 residents residing on Hall Y.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 2 (#2 and #4) of 4 (#1, #2, #3, and #4) residents reviewed for ADLs. The facility failed to ensure: 1. Staff made rounds on Resident #2 every 2 hours 2. Resident #4's hands were cleaned prior to meal time.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's right to be treated with respect and dignity for 2 (#2 and #3) of 4 (#1, #2, #3, and #4) sampled residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (#4) of 4 (#1, #2, #3, #4.) sampled residents reviewed for infection control practices. The facility failed to ensure resident hands were cleaned prior to dining.

Inspectors wroteBased on interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident. The facility failed to honor the resident smoking preferences for 6 (#R1, #R2, #R3, #R4, #R5, and #R6) out of 9 (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, and #R6) sampled residents reviewed for smoking.

Inspectors wroteFACILITY Sufficient and Competent Nurse Staffing Based on record review and interview, the facility failed to have documented evidence the Certified Nursing Assistant (CNA) Registry was verified for 5 (S10 CNA, S11 CNA, S12 CNA, S13 CNA and S14 CNA) of 5 (S10 CNA, S11 CNA, S12 CNA, S13 CNA and S14 CNA) CNA personnel records reviewed. This failed practice had the potential to affect any of the 95 residents residing in the facility who may receive care and services per the CNAs.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly. This could affect all 95 residents in the facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure a Resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The Facility failed to ensure a Resident's urinary catheter drainage bag was covered to ensure privacy for 1 (Resident #47) of 1 resident reviewed for dignity out of a total sample of 29 residents.

Inspectors wroteBased on record review and interview the facility failed to inform each resident as soon as was possible of changes in Medicare covered services as evidenced by the provider's failure to send the Centers for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage as required for 2 (#24, #143) of 2 residents reviewed for Beneficiary Notification who required the notification.

Inspectors wroteFACILITY Resident Assessment Based on record review and interview, the facility failed to ensure a discharge assessment was electronically transmitted in a timely manner within 14 days of completion for 1 (#18) of 1 residents reviewed for resident assessment.

Inspectors wroteBased on interview and record review the facility failed to maintain resident's highest practicable physical, mental and psychosocial well-being for 3 (Resident #15, Resident #42 and Resident #192) of 29 sampled residents by failing to implement their comprehensive person-centered care plan.

Inspectors wroteBased on observation, record review and interview the Facility failed to ensure the plan of care had been revised for 1 (#52) of 21 (#15, #58, #35, #62, #23, #87, #192, #91, #42, #64, #75, #68, #6, #29, #90, #30, #33, #47, #37, #54 and #52) Residents reviewed for plan of care out of a total sample of 29. The Facility failed to revise a Resident's plan of care for dialysis.

Inspectors wroteBased on observation, record review and interview the Facility failed to maintain a medication error rate of less than 5% for 1 (Resident #71) of 3 (Resident #71, Resident #4, and Resident #25) Residents observed during medication administration. A total of 31 opportunities were observed which included 2 medication errors for a medication error rate of 6.45%.