Colfax Nursing and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Colfax Nursing and Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF580Mar 3, 2023

  Based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in condition for 1 (#1) of 5 (#1, #2, #3, #4, & #5) residents reviewed for notification of change. The facility failed to timely consult with Resident #1's physician when Resident #1 experienced increased/worsening pain in her right lower extremity and a decline in ADLs due to increased pain, after treatment implemented by the physician was not effective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. […]

• Immediate jeopardy, widespreadF835Mar 3, 2023

  Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: Ensure nursing staff consulted with Resident #1's physician in a timely manner when Resident #1 experienced a significant change in her condition, and pain treatment was ineffective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. […]

• Immediate jeopardy, patternF697Mar 3, 2023

  Based on observation, interview, and record review, the facility failed to provide pain management cons istent with professional standards of practice for 1 (Resident #1) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: 1. Intervene and ensure Resident #1 received the necessary treatment/interventions when Resident #1 voiced and exhibited increased/worsening pain to her right lower extremity, and became bedfast due to the increased pain, after initial treatment of the increased pain by the physician was not effective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. […]

• Immediate jeopardy, isolatedF689Dec 10, 2021

  Based on observation, interview and record review, the facility failed to ensure that a resident who was identified as being at high risk for elopement, exhibited wandering and exit-seeking behaviors, and wore a secure care wander guard bracelet, was adequately supervised for 1 (#2) of 18 sampled residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). This failed practice resulted in an immediate jeopardy situation for Resident #2 on 10/24/2021 at approximately 5:10 a.m. when Resident #2 exited the facility without staff's knowledge through an unlocked patio door on wing 2, and through an opening in the patio gate. Resident #2 was found by facility staff 1.5 miles away at a local gas station, and brought back to the facility at 6:22 a.m. […]

• Actual harm, isolatedF686Apr 15, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident receives care consistent with professional standards of practice to prevent the development of avoidable pressure ulcers for 1 (#78) of 4 (#31, #63, #71, #78) sampled residents reviewed for pressure ulcers by failing to perform weekly body audits on a resident at risk for developing pressure ulcers. Findings: This deficient practice resulted in an actual harm for Resident #78 on 04/11/2021, when during an observation with S11 Treatment Nurse and S12 RN/Weekend Supervisor, Resident #78 was observed to have an undated, yellow, soiled gauze to the left heel. When the gauze was removed, there were two unstageable, foul-smelling pressure ulcers to the bottom and lateral side of the left heel. […]