Colby Operator, LLC

In the surveyor’s words

From the most serious findings on record at Colby Operator, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF610Mar 24, 2022

  The facility identified a census of 32 residents with four reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received the necessary protective oversight to prevent ongoing abuse and neglect when facility administrative staff failed to respond to an allegation of staff to resident abuse. On 03/19/22 at approximately 06:00 PM Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. At 10:30 PM staff reported the abuse to Administrative Staff A. The facility failed to implement protective measures after Administrative Staff A learned of the abuse allegation. […]

• Immediate jeopardy, isolatedF686Aug 12, 2024

  The 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. […]

• Immediate jeopardy, isolatedF600Mar 24, 2022

  The facility identified a census of 32 residents, with four reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 remained free from abuse and neglect when the facility failed to prevent an episode of staff to resident abuse, mistreatment, and neglect. On 03/19/22 at approximately 06:00 PM Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N witnessed CNA M yank on R1's arm and roughly reposition R1 in bed while R1 pleaded for help and screamed for CNA M to get out of the room. As a result of this occurrence, R1 was inconsolable and was left alone in her room where she subsequently had a fall an hour later. […]

• Immediate jeopardy, isolatedF609Mar 24, 2022

  The facility identified a census of 32 residents, with four reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure staff identified and immediately reported an allegation involving abuse, neglect, or mistreatment. On 03/19/22 at 06:00 PM Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N responded to cognitively impaired Resident (R) 1 screams for help. When LN G and CNA N entered R1's room, they witnessed CNA M roughly yanking on R1's arm and roughly repositioning R1 in bed while R1 screamed out for help and yelled to CNA M to get out of the room. LN G and CNA N failed to immediately report the witnessed abuse to Administrative Staff A until 4.5 hours after the event, at 10:30 PM. […]

• Actual harm, isolatedF689Dec 12, 2022

  The facility identified a census of 28 residents, with three reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had foot pedals on his wheelchair when Certified Nurse Aide (CNA) M attempted to push R1 in his wheelchair to the nurse's station. As a result, R1 put his foot down on the ground and the wheelchair abruptly stopped, flipping R1 out of the wheelchair and forward onto his face, which resulted in a laceration to his right eyebrow. R1 had to be transported to the emergency room for sutures to be placed to his laceration. […]