Colfax Health and Rehabilitation of Cascadia

In the surveyor’s words

From the most serious findings on record at Colfax Health and Rehabilitation of Cascadia, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jul 22, 2024

  Based on observation, interview and record review, the facility failed to ensure that 4 of 4 residents who were assessed to smoke independently (Resident 30, 31, 24, and 20) had a designated safe location to smoke, fire-safe receptacle for disposal of cigarette butts, and a system in place to ensure smoking supplies were stored safely. In addition, the facility failed to ensure smoking evaluations were done timely for 1 of 1 sampled resident (Resident 22) reviewed for smoking. […]

• Immediate jeopardy, isolatedF689Sep 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe transportation for 1 of 4 sample residents (1), reviewed for transportation to an appointment in the facility van, with a driver and accompanied by a second staff. The facility failed to ensure the safety belts in the vehicle were in good repair and functioning. These failures resulted in serious physical and psychosocial harm to one resident when they sustained a fall from the wheelchair during the transportation to the appointment, resulting in a fractured leg and subsequent amputation, and placed other residents at risk for serious injury, impairment, or death during transportation. The facility has corrected all the above deficiencies prior to the abbreviated survey. […]

• Actual harm, isolatedF684Apr 7, 2026

  Based on interview and record review, the facility failed to timely identify and address a decline in condition for 1 of 3 residents (Resident 1) started on a new medication. Resident 1 experienced harm when they had a decline in condition as evidenced by nausea/vomiting, change of level of consciousness, were difficult to arouse, and became unresponsive after starting a new partial opioid (buprenorphine-naloxone (suboxone) - a central nervous system depressant used to treat opioid addiction) medication. […]

• Actual harm, isolatedF600Jul 22, 2024

  Based on observation, interview, and record review the facility failed to protect a resident's right to be free from physical and psychological abuse by another resident for 1 of 2 sampled residents (Resident 28) reviewed for abuse. Resident 28 experienced psychological as evidenced by a change in behaviors, being up at night, pacing and fear. This failure placed residents at risk for physical and psychological abuse, and a diminished quality of life. Findings included . Review of the facility policy Abuse Prevention, Identification and Reporting and Investigating, dated 10/31/2017, directed protocol for Protection of a Patient during an investigation if resident to resident abuse occurred. The policy stated . […]

• Actual harm, isolatedF689Oct 12, 2023

  Based on interviews and record review the facility failed to ensure supervision was provided following a decline in function, recent fall from the toilet and recent unconscious episode to 1 of 3 residents (Resident 1) reviewed for falls with injuries. Despite Resident 1's changes in condition their plan of care was not revised to address the need for additional staff supervision with toileting. This failed practice resulted in actual harm to Resident 1 who fell from the toilet after being left unsupervised by staff. […]