Colonial Acres of Humboldt

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure that expired foods were discarded and open packages of dry food were dated with month, date, and year. This had the potential to affect all residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19(c)Based on observations and interviews, the facility failed to ensure clean linens were delivered in a covered cart to prevent potential cross contamination. This had the potential to affect all 30 residents who resided at the facility.

Inspectors wroteBased on record reviews and interviews the facility failed to maintain staff documentation of offering the COVID-19 vaccine, education on the COVID-19 vaccine, and current vaccine status for 5 of the 5 sampled employees. This had the potential to affect all residents and staff who live and work at the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Based on record reviews and interviews, the facility failed to ensure the required 12 hours of annual ongoing training was provided for nurse aides. This had the potential to affect all residents. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G)(i) Based on record reviews and interviews, the facility failed to provide a notice of transfer to the hospital and a bed hold policy to the resident and the resident's representative. The facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their wellbeing) of the transfer for 3 of 3 sampled residents (Resident 3, Resident 5, and Resident 30). The facility failed to ensure a discharge summary including a recapitulation (summary) of stay was completed for Resident 31 upon death. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04DBased on observations and interviews, the facility failed to ensure bathroom ventilation systems were functioning to prevent odors for rooms 200, 201, 203, 205, 207, 209, 211 and 213 and the ventilation was clean from debris. This had the potential to affect all residents who reside on the 200 hall. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D)Licensure Reference Number 175 NAC 12-006.05(E)Based on record reviews and interviews the facility failed to ensure that the resident or the resident representative was informed of the risks, benefits and alternative treatments for the use of psychotropic medications (any medication that affects behavior, mood, thought, or perception, used to manage mental health conditions) as required, for 2 of 2 sampled residents (Resident 1 and Resident 8). The facility census was 30.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop a baseline care plan (a document that serves as initial instruction and guidance for the resident's care), for 1 resident (Resident 33) of 2 sampled residents. The baseline care plan did not contain information and interventions for the use of psychotropic medications. The facility's census was 30.

Inspectors wroteBased on observations and record reviews, the facility failed to ensure staffing information was posted as required. This had the potential to affect all residents. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B) & 1-005.06 Based on observations, interviews, and record reviews; the facility failed to utilize Enhanced Barrier Precautions (EBP, a set of infection control measures that aim to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes), to reduce the potential for transmission of infection during high contact resident care activities related to Resident 27's indwelling urinary catheter, Resident 22's wound, urostomy, and colostomy, Resident 129's tube feeding, Resident 131's wound, and Resident 18's wound. The sample size of residents was 27. The facility census was 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and observations, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning purposes) reflected the status of Resident 27's catheter at the time of admission. The sample size was 13. The facility census was 27. Findings Are: On 9/30/24 at 11:42 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. On 10/1/24 at 9:00 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP-written instructions needed to provide effective and person centered care of a resident that meet professional standards of quality care) for 1 (Resident 27) of 2 sampled resident's catheter cares. The facility census was 27. Findings Are: On 9/30/24 at 11:42 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. On 10/1/24 at 9:00 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC-12-006. 11E Based on observation, interview and record review; the facility failed to ensure outdated foods were not available for use, failed to label and date opened food and failed to utilize handwashing and gloving techniques to prevent the potential for food borne illness This had the potential to affect all the residents. Facility census was 31.

Inspectors wroteBased on record review and interviews, the facility failed to complete a level 2 PASARR (necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) assessment for 2 of 2 sampled residents (Resident 22 and Resident 23) after a new diagnosis of a serious mental disorder was received. The facility had a census of 31.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09C3 Based on interview and record review the facility failed to complete a recapitulation of stay for 2 (Residents 32 and 33) of 2 sampled residents. The facility staff identified a census of 31.