Colfax General LTC
For profit - Partnership
34 Beds
Independent
Data: November 2025
Trust Grade
35/100
#31 of 67 in NM
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Colfax General LTC has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #31 out of 67 nursing homes in New Mexico, placing it in the top half of facilities in the state, but it is the second of only two options in Colfax County, meaning there is only one local competitor. Unfortunately, the facility's issues are worsening, with the number of reported problems increasing from 3 in 2024 to 9 in 2025. Staffing is a major concern, with a poor rating of 1 out of 5 stars and an alarming turnover rate of 85%, well above the state average. While there have been no fines, which is a positive aspect, serious incidents include neglect that delayed emergency treatment for an injured resident and inadequate pain management for another resident with a fractured arm, both of which highlight weaknesses in care. Additionally, the facility failed to provide necessary behavioral health services for a resident, leading to serious consequences, including an assault on staff.
- Trust Score
- F
- In New Mexico
- #31/67
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 85% turnover. Very high, 37 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Mexico facilities.
- Skilled Nurses ✓ Good
- Each resident gets 57 minutes of Registered Nurse (RN) attention daily — more than average for New Mexico. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Top 46%
Review needed
3 → 9 violations
★★★☆☆
3.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 9 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near New Mexico average (2.9)
Meets federal standards, typical of most facilities
Staff Turnover: 85%
38pts above New Mexico avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is very high (85%)
37 points above New Mexico average of 48%
The Ugly 30 deficiencies on record
3 actual harm
Apr 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's provider of a decline in condition for 1 (R #...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's provider of a decline in condition for 1 (R #1) of 1(R #1) resident reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider when the resident experiences a change of condition, then the provider is unable to make decisions related to treatment and advocate for the resident's care. The findings are:
A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:
-Acute Kidney Failure (condition in which the kidneys can't filter waste from the blood).
-Dementia (memory loss).
-Chronic Obstructive Pulmonary Disease unspecified (shortness of breath).
-Alcoholic Cirrhosis (damage of cells, swelling, and thickening of the liver).
-Cerebral Vascular Accident (Stroke).
-UTI (Urinary Tract Infection).
B. Record review of R #1's daily care/progress notes revealed the following:
- On 03/11/25, R #1 had refused to eat for a couple of days.
- On 03/12/25, R #1's Medical Doctor (MD) progress notes stated that if R #1's condition did not improve in 24 hours, Staff will need to consider Emergency Department (ED) evaluation and hydration. The progress note further stated, nurses will contact providers with any concerns or changes.
-On 03/16/25, R #1 was sent to the emergency room (ER) for a decline in condition. Due to sepsis (systemic infection) and UTI, R #1 was transported via air medical transport to [NAME], Texas for specialty evaluation and care.
-The record did not contain any progress notes from 03/13/25 through 03/15/25 documenting R #1's health status, evaluations, or a decline in condition.
-On 03/16/25 the progress note stated, R #1 presents with altered mental status, R #1 had 5 teeth removed on 02/25/25. The gums at removal sites are yellowish green.
C. On 04/22/25 at 2:47 pm during an interview with Registered Nurse (RN) #1, she confirmed that staff should have called or texted the physician concerning any change in condition.
D. On 04/22/25 at 3:11 pm during an interview with the Director of Nursing (DON), she confirmed the Medical Doctor (MD) should have been notified.
E. On 04/22/25 at 3:56 pm during a phone interview with Provider #1, he stated that he was not notified of R #1's decline in condition.
F. On 04/22/25 at 3:57 during a phone interview with Provider #2, she stated she was not notified of R #1's decline in condition.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 1 (R #13) of 5 (R #2, #3, #4, #5, and #13...
Read full inspector narrative →
Based on observation and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 1 (R #13) of 5 (R #2, #3, #4, #5, and #13) residents observed for call lights. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff.
The findings are:
A. On 04/22/25 at 9:17 am during a call light observation, R #13's call light was activated, but it did not sound at the nurse's station or the unit to alert staff of call light activation. The call light did not activate the marquee (electronic signage displaying room numbers) notification, the nurse's station visual alert or nurse's station audible alert.
B. On 04/22/25 at 9:20 am during interview with Registered Nurse (RN #1), RN #1 stated call lights should alert staff at the nurses station when activated and should display on marquee in the unit halls. RN #1 confirmed R #13's call light did not alert the nursing station when activated nor display on marquee of the call light and should have.
C. On 04/22/25 at 9:25 am during interview with Certified Nursing Assistant (CNA) #1, she confirmed R #13's call light was not functioning. CNA #1 stated R #13's call light should be fully functioning when activated and it was not.
D. On 04/22/25 at 9:36 am during a call light observation, R #13's call light was activated two more times and did not alert nurses station or display notification on marquee.
E. On 04/22/25 at 9:36 am during an interview with CNA #1, she confirmed R #13's call light was still not functioning properly, and should have been. CNA #1 will notify maintenance.
F. On 04/23/25 at 3:11 pm during an interview with Director of Nursing (DON), she stated, she was not notified of a call light issue. DON stated the facility policy is that the CNAs should report the malfunction to the charge nurse, then report the malfunction to maintenance. DON stated, while the call light is not working, staff should be rounding on the affected room every 30 minutes to ensure resident safety. DON confirmed the 30 minute room rounding was not occurring, and R #13's call light should have been fixed already.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to meet professional standards for 3 (R # 5, 6, and 7) o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to meet professional standards for 3 (R # 5, 6, and 7) of 9 (R #1, 5, 6, 7, 8, 9, 10, 11, and 12) residents when staff failed to:
1. Ensure R #5's, R #6's, and R #7's humidity (attachable bottle to moisten administered oxygen) is added to concentrator and that O2 concentrator is capable of having humidy added.
2. Label and date oxygen (O2) tubing per physician orders for R #5, R #6 and R #7.
If the facility is not following physician orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment.
The findings are:
R #5:
A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE].
B. Record review of R #5's physician orders dated 02/28/25, revealed an order to change humidifiers (device used to moisten medical O2) and nasal cannulas (device used to administer medical O2) on the night shift every Friday.
C. On 04/22/25 at 2:06 pm during an observation of R #5's room, R #5's concentrator (oxygen machine) did not have a humidifier as ordered by Physician and the O2 tubing was not labeled or dated .
R #6:
D. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE].
E. Record review of R #6's physician orders dated 02/28/25, revealed change humidifier/cannulas, date and initial every night shift every Fri (Friday).
F. On 04/22/25 at 2:08 pm during an observation of R #6's room, R #6's concentrator did not have a humidifier as ordered. Label and dates were missing from the equipment.
R #7:
G. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE].
H. Record review of R #7's physician orders dated 02/28/25, revealed an order to change humidifiers and nasal cannulas on the night shift every Friday.
I. On 04/22/25 at 2:10 pm during an observation of R #7's room, R #7's concentrator was found to be without a humidifier. Label and dates were missing from equipment.
J. On 4/22/25 at 2:20 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated the humidifier bottle and tubing should be changed weekly. CNA #2 confirmed staff are supposed to label and date the tubing and bottle. CNA #1 stated she is unaware of how humidity can be added to the affected resident concentrators.
K. On 4/22/25 at 2:47 pm during an interview with Registered Nurse (RN) #1, she stated the CNAs and nurses are responsible for changing O2 tubing and the humidifiers as ordered by Physician. RN #1 confirmed the nasal cannulas and humidifier should be labeled and dated. RN #1 stated she doesn't know how to change or add humidity to the affected resident concentrators. RN #1 stated, I would expect these concentrators are to be replaced and be able to administer humidified air.
L. On 4/22/25 at 3:11 pm during an interview with the Director of Nursing (DON), she stated, all the residents with concentrators should have a concentrator that is capable of adding humidity. The DON confirmed the affected resident concentrator was not capable of adding humidity.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure:
1. Food items were labeled and dated in the kitchen refrigerator ...
Read full inspector narrative →
Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure:
1. Food items were labeled and dated in the kitchen refrigerator and freezer.
2. Food was stored appropriately and not left open to air in the kitchen freezer.
These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 04/21/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.
The findings are:
A. On 04/21/25 at 1:03 pm, observation of the kitchen revealed the following:
- 3 pecan pies, 3 apple pies, 1 sheet cake, and 1 box of salmon fish fillets were not labeled or dated and stored in the kitchen freezer.
- 1 package of pepperoni, 1 pack of chicken nuggets, and 1 box of salmon fish fillets were open to air and stored in the kitchen freezer.
- 1 box of eggs was sealed but was not labeled or dated in the kitchen refrigerator.
- 2, 12 pack soda cases were stored on the floor in the dry storage, and one case had been opened.
B. On 04/21/25 at 1:34 pm during an interview with the Dietary Manager (DM), he confirmed all items listed on finding A and stated that all food items should be labeled, dated, stored appropriately.
Jan 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #34) of 1 (R #34) residents reviewed for advance directives.
This deficient practice is likely to cause confusion and delay potentially life saving procedures. The findings are:
A. Record review of R #34's physician orders dated [DATE] revealed R #34 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status.
B. Record review of R #34's care plan dated [DATE] revealed R #34 was a DNR for her advanced directive code status.
C. Record review of R #34's face sheet revealed R #34 was admitted into the facility on [DATE].
D. Record review of R #34's EHR revealed the record did not contain an advanced directive form.
E. On [DATE] at 2:04 pm during an interview with the Social Services Director (SSD), she confirmed R #34's advanced directive code status was not uploaded into R #34's EHR nor was it available in physical form for nursing staff and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report the results of an investigation regarding allegations of abuse for 2 (R #'s 8 and 22 ) of 2(R #'s 8 and 22) residents reviewed for i...
Read full inspector narrative →
Based on record review and interview, the facility failed to report the results of an investigation regarding allegations of abuse for 2 (R #'s 8 and 22 ) of 2(R #'s 8 and 22) residents reviewed for incidents.
If the facility is not submitting the summary of the facility's investigation to the State Agency (SA), then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are:
A. Refer to F0610 for related findings.
B. On 01/30/25 at 2:33 pm during an interview with the Administrator (ADM), she stated the incident involving R #8 and R #22 with an agency Certified Nurse Assistant (CNA) was not reported to the SA. The ADM stated that R #8 only reported experiencing issues with the agency CNAs bedside manner towards him and R #22, but the facility could not define what bedside manner meant in this case. When asked if this could be considered verbal abuse, the ADM was unsure and stated she could not rule out verbal abuse with the information that was provided to her. The ADM confirmed all allegations of abuse, including verbal abuse, should be reported to the SA.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a thorough investigation and report the investigation find...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days, for an allegation of abuse for 2 (R #'s 8 and 22) of 2 (R #'s 8 and 22) residents reviewed for incidents.
If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation. The findings are:
A. Record review of the facility's investigation report dated 12/23/24 revealed the following:
- R #8 requested to speak to the Administrator (ADM) regarding concerns of bedside manner of an agency Certified Nursing Assistant (CNA) while assisting R #22.
-R #8 stated that his back was turned when the agency CNA assisted R #22, he had concerns of poor bedside manner regarding that interaction.
- Multiple residents were interviewed on 12/23/24 with the residents confirming poor attitude and bedside manner experienced by the agency CNA.
- Due to the residents consistent highlighted concerns regarding the agency CNAs bedside manner, the agency CNAs contract was terminated.
B. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE].
C. Record review of R # 8's Minimum Data Set (MDS- Resident Assessment and Care Screening) Section C: Cognitive Patterns- Brief Interview for Mental Status (BIMS: assessment used to monitor cognition; 0 to 7 points equals severely impaired cognition, 8 to 12 points equals moderately impaired cognition, and 13 to 15 points equals intact cognition) dated 11/14/24 revealed R #8 was scored as 15.
D. Record review of R #8's nursing progress notes dated 12/20/24 through 01/01/25 revealed the notes did not contain any documentation of any allegations of abuse against an agency CNA (Certified Nursing Assistant) for R #8.
E. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE].
F. Record review of R #22's MDS Section C: Cognitive Patterns- BIMS dated 11/27/24 revealed R #22 was scored as 11.
G. Record review of R #22's nursing progress notes dated 12/20/24 through 01/01/25 revealed no notes were present that indicated any allegations of abuse against an agency CNA for R #22.
H. On 01/27/25 at 4:42 pm during an interview with R #22, he stated that he could not remember any incidents involving staff.
I. On 01/28/25 12:42 pm during an interview with R #8, he stated that several weeks ago an agency CNA did not talk to him nicely and had poor bedside manner. R #8 also stated that the agency CNA was rough with his roommate (R #22) on two different occasions which resulted in R #22 screaming out in pain. R #8 confirmed that he reported all incidents to the nursing staff and the ADM.
J. On 01/29/25 at 4:01 pm during an interview with an anonymous employee (AE), they stated the incident involving R #8 and R #22 occurred sometime around 12/21/24 through 12/22/24. R #8 informed the AE that the agency CNA was rough with R #22, which caused R #22 to be in pain. The AE also stated this incident should have been reported to the SA, but it was not because R #22's arms did not have trauma to the skin.
K. On 01/29/25 at 5:32 pm during an interview with Registered Nurse (RN) #1, she stated she heard about this incident (incident involving an agency CNA and R #'s 8 and R #22) as a rumor outside of the facility, but she was not involved with any part of the incident.
L. On 01/30/25 at 9:43 am during an interview with CNA #1, she stated R #8 called her to his room after the incident with the agency CNA and reported that the agency CNA was rough with R #22 and rude to R #8. CNA #1 confirmed she informed the previous Assistant Director of Nursing (ADON) right away, and the previous ADON stated she would investigate the incident. The CNA #1 also stated that she did not remember the date when she informed the previous ADON.
M. On 01/30/25 at 11:01 am during an interview with RN #2, she stated she was not there for the incident with R #8 and R #22, but the facility reporting process is for nursing staff to notify management so a complete investigation can be conducted.
N. On 01/30/25 at 12:27 pm during an interview with RN #3, she stated she reported the incident regarding R #8 and R #22 to the ADM as soon as she was aware of what allegedly happened. RN #3 stated R #8 informed her that when the agency CNA was assisting and turning R #22, R #22 screamed very loudly and in a way R #8 had never heard before (sometime during the dates of 12/21/24 through 12/22/24). RN #3 confirmed R #8 was completely cognitive, so she reported the allegations of abuse involving R #8, R #22, and the agency CNA to the ADM. RN #3 also confirmed that she immediately assessed R #22 for injury (on 12/22/24), but due to R #22's cognitive decline, R #22 denied any concerns and R #22 did not have any injuries present. RN #3 also stated she believed the agency CNA pulled R #22's arm too roughly, which caused pain. RN #3 confirmed that she wrote a statement about R #8 and R #22's abuse allegations involving the agency CNA, and RN #3 delivered the statement to the ADM in the morning on 12/23/24.
O. On 01/30/25 during an interview with the ADM, she stated that she talked to R #8 because of the concerns of R #8 had involving the agency CNA and how the agency CNA treated R #8 and R #22. The ADM stated R #8 informed her that the agency CNA was rude to R #8 and R #22, so she had an internal investigation completed. The ADM also stated that abuse was not reported to her after a facility team completed the investigation and staff did not provided her with any information about the agency CNA being rude to R #8 and R #22. The ADM confirmed that if she had been made aware of abuse allegations, then she would have reported the incident to the SA, but she did not.
P. On 01/30/25 at 3:05 pm during an interview with the Social Services Director (SSD), she stated she was informed of this incident by the ADM on 12/23/24, so she was a part of the investigation team that reviewed the allegations of poor bedside manner and staff rudeness towards R #8 and R #22. The SSD stated that she interviewed R #8 and R #22 on 12/23/24. The SSD also stated that she was not made aware of staff roughness towards R #22 by the agency CNA during the investigation, so that was not investigated. The SSD confirmed that she was unaware of facility nursing staff having information related to this incident because she only interviewed residents during the investigation for the allegation of abuse involving R #8 and R #22, and facility staff was not interviewed during this investigation. The SSD also confirmed that if she had gotten more information from residents about the agency CNA being rough with R #22, then she would have interviewed facility nursing staff as well.
Q. On 01/30/25 at 3:52 pm during an interview with the Interim Director of Nursing (DON) and new DON, they both confirmed that they would expect facility nursing staff to be interviewed during an investigation for allegations of abuse involving residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to e...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure:
1. Food items were labeled and dated in the kitchen refrigerator and freezer.
2. Kitchen refrigerators were free from dietary staff personal food.
3. Food was stored appropriately and not left open to air in the kitchen.
4. Salad was stored on ice prior to meal service.
These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 01/27/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.
The findings are:
A. On 01/27/25 at 12:39 pm, observation of the kitchen revealed the following:
- One Styrofoam To-Go container labeled [Name of [NAME] 1] dated 01/27/25 was stored in the kitchen refrigerator.
- Three large plastic bags of crinkle cut fries were not labeled or dated and stored in freezer #1.
- One large plastic bag of frozen meat was not labeled or dated and stored in freezer #1.
- Seven large plastic bags of biscuits were dated 11/09 but not labeled and stored in freezer #1.
- Two large plastic bags of cubed meat dated 12/01 but not labeled and stored in freezer #2.
- Four large bags of chicken tenders dated 12/01 but not labeled and stored in freezer #2.
B. On 01/27/25 at 12:53 pm during an interview with the Dietary Manager (DM), he stated that all food should be labeled, dated, and staff should not store their food in the resident refrigerator.
C. On 01/30/25 at 11:45 am, observation of the kitchen revealed one box of 20 count [NAME] Spunkmeyer muffins were left open to air and stored on a kitchen table near freezer #2.
D. On 01/30/25 at 11:47 am during an interview with the DM, he confirmed the muffins were left open to air and stated they should have been sealed for storage.
E. On 01/30/25 at 12:04 pm, observation of the dining room revealed the following:
- One plastic container of salad mix and one plastic container of chopped tomatoes were stored on the hot steam table, the salad mix and the tomatoes were not on ice while the DM served the residents their lunch plates. The salad was served to all residents in dining room.
F. On 01/30/25 at 12:05 pm during an interview with the DM, he confirmed the salad mix and tomatoes were not cold and stated they should have been stored on ice during meal service.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure that all garbage and refuse containers have lids or are otherwise covered in the kitchen. This deficient practice could likely affect ...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure that all garbage and refuse containers have lids or are otherwise covered in the kitchen. This deficient practice could likely affect all 32 residents identified on the resident census list provided by the Administrator on 01/27/25.
This deficient practice could likely result in shelter and feeding of pests. The findings are:
A. On 01/30/25 at 11:45 am, observation of the kitchen revealed the following:
- One small trash can filled with trash was not covered and stored under the dishwashing station next to an open box of muffins.
- One large trash can was filled with trash and not covered next to the three compartment kitchen sinks and stove.
B. On 01/30/25 at 11:48 am during an interview with the Dietary Manager (DM), he confirmed both trash cans were uncovered in the kitchen near food prep areas. The DM stated all trash cans should be stored with lids.
Jan 2024
3 deficiencies
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to assure medications and other medical supplies were properly stored an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to assure medications and other medical supplies were properly stored and not expired. This deficient practice had the potential to affect all 28 residents identified on the facility census list provided by the Director of Nursing (DON) on 01/16/24. Improperly stored medications and medical supplies could likely lead to confusion and possibly result in residents being administered expired medications and supplies.
The findings are:
Medication Storage Room
A. Observation on 01/16/24 at 2:01 pm, during a routine check of the facility medication storage room, revealed the following:
1. One container of Clorox Bleach Germicidal wipes expired on 04/14/22,
2. One, 30 gram (g) bottle of Nystop (Nystatin) powder (an antifungal, antibiotic powder used to
treat skin infections caused by yeast) expired on 05/23/22,
3. One open bag of Goodsense cough drops, menthol flavor, 30 drops, expired on 07/01/22,
4. One jar of Vicks VapoRub (an ointment to help relieve cough, congestion, sore muscles, and
toenail fungus), 3.52 ounce (oz) expired 04/01/22,
5. Two boxes On-call Express Lancet Strips (used to test blood sugar levels), 50 strips each,
expired on 08/26/23 and 11/04/22,
6. Three boxes of On-Call Express Glucose Control Solution (used to calibrate glucometer
machine which tests blood sugar levels) Lot #RT80238, Lot #RT80127,Lot #RT 80283 which
expired on 10/16/21,01/08/20, 05/22/22,
7. One box Medline Safety needles, 25 gauge (G) by 5/8 inch (), 100 count, Lot #15030212
expired on 03/01/2020,
8. One box [NAME] Point syringe, 3 milliliter (mL), 25 G by 1, Lot #A170706 expired on
06/28/22,
9. One box [NAME] Point syringe, 3 mL, 25 G by 1 with needle, 100 count, Lot #A170706
expired on 06/28/22,
10. One Box Insulin syringe, 100 units (U), 31 gauge, 60 count, Lot #NP20188 expired on
06/21/23,
11. One Box [NAME] Point syringe with needles, 3 mL, 27 G by 1 1/2, 100 count, Lot
#A160606 expired on 05/01/21,
12. One Box [NAME] Point syringe, 3 mL, 25 G by 1, 100 count, Lot #A180604 expired on
05/28/23,
13. One Box [NAME] Point syringe with needle, 3 mL, 25 G by 5/8, 100 count, Lot #G171106
expired on 10/28/22,
14. One Box [NAME] Point syringe with needle, 3 mL, 27G by 1 1/2, 100 count, Lot #A160606
expired on 05/01/21,
15. One Box [NAME] Point syringe with needle, 25 G by 5/8, 100 count, Lot #G181104 expired
on 10/28/23,
16. Safety Needle, 25 G by 5/8, 24 count, Lot #15030212 expired on 03/2020,
17. Two [NAME] (BD) safety needles, 25 G by 1, Lot #6117885 expired on 0
4/01/21.
B. On 01/16/24 at 2:35 pm during interview with RN #1, she confirmed the medical supplies were expired and should not be stored in the medication storage room.
C. On 01/16/24 at 2:40 pm during interview with Director of Nursing (DON), she confirmed the medical supplies were expired and were not stored properly.
Medication Storage Cart
D. On 01/16/24 at 3:50 pm, during a routine check of the facility medication storage cart, two pills lay in the bottom of the second drawer. One small, oval, white pill had 17/11 stamped on it, and one, small, round orange pill had L15 stamped on it. Further observation revealed two loose pills lay in the bottom of the third drawer. One small, round, white pill did not have a stamp or identifying marks, numbers or letters; and one small, round, yellow pill had sg on one side and 458 on the other side.
E. On 01/16/24 at 4:00 pm during interview with RN #1, she confirmed the pills in bottom of drawer were outside of their original, labeled packaging and were not stored properly inside the medication storage cart.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on an interview the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows:
(A) A certified dietary manager; or
(B) A certified food service manager; o...
Read full inspector narrative →
Based on an interview the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Had similar national certification for food service management and safety from a national
certifying body; or
(D) Had an associate's or higher degree in food service management or in hospitality, if the c
ourse study includes food service or restaurant management, from an accredited institution of
higher learning; or
(E) Had two or more years of experience in the position of director of food and nutrition
services in a nursing facility setting and has completed a course of study in food safety and
management, by no later than October 1, 2023, that included topics integral to managing
dietary operations including, but not limited to, foodborne illness, sanitation procedures, and
food purchasing/receiving.
This deficient practice is likely to affect all 28 residents living at the facility. Residents are likely not to receive the dietary nutritional services needed to thrive and their needs will not be met.
The findings are:
A. On 1/18/24 at 2:20 PM, during an interview with the Cook, he stated he was not certified as a Dietary Manager (DM). He also stated the company offered him the position of DM, but he has not decided if he was going to accept the position.
B. On 1/18/24 at 2:30 PM, during an interview with the facility Administrator (ADM), she stated she was aware the cook was not certified and the facility offered him the DM position. The ADM stated the DM was an interim currently. ADM stated that they should have a CDM and she is working on getting Certified as a Dietary Manager.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety. This...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety. This deficient practice is likely to affect all 28 residents identified on the resident census list provided by the Director of Nursing (DON) on 01/16/24. These deficient practices are likely to expose residents to food borne illnesses. The findings are:
A. Observation on 01/16/24 at 11:53 am, during initial observation of the facilities food storage area, revealed the following: Please note the following items listed below were opened.
1. One box of 20 pounds of frozen stuffed bell peppers opened and not dated.
2. One box of 20 pound (lb) beef stroganoff opened and not dated.
3. One box of sausage patties opened and not dated.
B. Observation on 01/16/24 at 12:00 pm, during observation of the facilities food storage area, revealed the following:
1. One box of 24 ounce (oz), citrus gelatin opened and not dated.
2. One box of 24 oz, red assorted gelatin opened and not dated.
3. One box containing Spanish rice opened and not dated.
4. One box containing long grain rice opened and not dated.
5. One 60 count box of variety potato chips opened and not dated.
C. On 01/16/24 at 12:12 pm during interview with facility cook, he confirmed all items listed above were not dated. The cook further stated that staff was told to place items on the shelves and only label them when they are opened. This practice is not in accordance with professional standards of food service safety.
Jul 2023
6 deficiencies
2 Harm
SERIOUS
(H)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent neglect for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents by:...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent neglect for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents by:
1. Delay in sending R #1 to emergency room for evaluation and treatment after sustaining an injury
2. Not closely monitoring the injured site for changes in condition
3. Provider not completing a thorough physical assessment of the injury
These deficient practices likely resulted in R #1's delayed transfer to the Emergency Department (ED) and receiving critical care required for an arm fracture. If the facility is not monitoring for residents' change in condition, properly assessing residents with significant injuries, or communicating with providers effectively, then residents are likely at risk of inadequate or delayed treatment.
The findings are:
A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses:
1. Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms like progressive breathlessness and cough)
2. Hypertension (high blood pressure)
3. Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart)
4. Pleural Effusion (fluid-filled space that surrounds the lungs)
5. Cyst of Kidney (fluid-filled pocket that can form inside your kidneys)
6. Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly)
7. Chronic Kidney Disease
8. Pulmonary Embolism (one of the pulmonary arteries in the lungs gets blocked by a blood clot)
9. Heart Failure
B. Record review of R #1's care plan dated [DATE] revealed, Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t [related to] Fatigue. Interventions: BED MOBILITY: The resident is totally dependent on 1 staff for repositioning and turning in bed as necessary, and TRANSFER: The resident requires extensive assist by 1 staff to move between surfaces as necessary.
C. Record review of R #1's progress notes dated [DATE] at 4:05 pm revealed, Was made aware by CNA (Certified Nursing Assistant) that resident (R #1) was having R [right] elbow pain with visible swelling. Assessed residents R [right] elbow, swelling evident, with 1x1 [1 inch by 1 inch] skin tear and hematoma (bad bruise). [ .] Notified POA (Power Of Attorney) and PCP (Primary Care Physician) of incident.
D. Record review of R #1's MD (Medical Doctor) progress notes completed by Nurse Practitioner (NP) dated [DATE] at 1:33 pm revealed, No concerns noted by staff admitted to LTC [Long Term Care] because she cannot safely care for herself at home. Musculoskeletal [relating to or denoting the musculature and skeleton together]: no gross bony deformities.
E. Record review of R #1's physician orders dated [DATE] at 7:04 am revealed, Send to ER (Emergency Room) for treatment and evaluation per doctor order. R #1 was sent to the ER via ambulance on [DATE].
F. Record review of R #1's ER History and Physical (HPI) dated [DATE] at 8:40 am revealed, This is a [AGE] year-old female with a history of dementia, hypertension, chronic atrial fibrillation not anticoagulated, COPD on 2 liters/minute of oxygen via nasal cannula, chronic kidney disease, pulmonary embolism, peripheral arterial disease with chronic right lower extremity wound and congestive heart failure brought in by ambulance for evaluation of an injury to the right elbow. History provided by nursing home staff and EMS (Emergency Medical Services) is that there was no reported fall. However, when the patient's [R #1's] daughter arrived, she [R #1's daughter] states that she received a call from the nursing facility 2 days ago stating that the patient had hit her elbow on the left. This morning, she [R #1's daughter] received another call from the facility stating that her mother's elbow was dislocated and had an open wound. No additional history provided. Patient [R #1] is unable to provide any history. Patient [R #1] denies any acute complaints, although has pain with any movement of her right upper extremity. Nursing staff reported to the ED (Emergency Department) staff that the patient has been hallucinating (a perception of having seen, heard, touched, tasted or smelled something that wasn't actually there) and trying to get out of bed. Right upper extremity Ace wrap reportedly applied by nursing home staff. Right upper extremity splint applied by EMS.
G. Record review of R #1's ER Hospital Note dated [DATE] at 8:40 am revealed, R #1 was diagnosed with Open fracture of right humerus, Sternal fracture, and laceration (cut) on back amongst other chronic illnesses.
H. On [DATE] at 4:18 pm during an interview with R #1's daughter, she stated, The facility called me on a Tuesday [[DATE]] and told me my mother had bumped her elbow on the wheelchair and they were letting me know she was getting pain medication. The next day [[DATE]], I called down there and asked how she [R #1] was doing. They said she was doing ok and her elbow hurt and they were giving her medicine. It [R #1's injury] happened on Tuesday [[DATE]] and on Thursday [[DATE]], when they called me, they [facility] said she [R #1] was on her way up here to [name of ER] and they said they think she dislocated her elbow. Her [R #1] arm was broken. They [local ER] sent her [R #1] to [Name of trauma center] and they were filing for elder abuse. They [local ER] told me her skin had split. My mother's skin was really dry. I don't know if they [facility staff] scraped her arm on something but I have no idea. They [trauma center] put her [R #1] on hospice because she could not survive the surgery. They suggested she be put on hospice, I put my mom [R #1] on hospice and she only lasted two days. She had two breaks in her arm.
I. On [DATE] at 10:00 am during an interview with Registered Nurse (RN) #1, she stated, I assessed her [R #1 on [DATE] at 4:01 pm]. The Nurse Practitioner (NP) was coming in on Wednesday [[DATE]], but I let her (NP) know what I saw [via the phone on [DATE]]. I felt both [of R #1's] elbows. I didn't feel a dislocation in her [R #1] elbow. I gave her [R #1] the tramadol (pain medication) and let the NP know. The next day [[DATE]], the NP came in and we followed up on her [R #1]. When I talked to [R #1] that day [[DATE]], and she [R #1] said she wasn't having as much pain [in R #1's right arm], but she was just sore. The swelling was consistent [on R #1's right arm]. At the end of the day [[DATE]], [Name of NP] left and I didn't get to follow up [with NP regarding R #1]. I called her [NP on [DATE]] and she [NP] said to continue monitoring her [R #1 on Wednesday [DATE] after the NP assessed R #1]. [Name of Certified Nursing Assistant (CNA) #6] said she [R #1] was having a complaint of elbow pain after the transfer with the sit to stand transfer on [DATE]. She [R #1] didn't fall and the CNA's said she [R #1] didn't have a fall. [Name of CNA #1] was the one lifting her [R #1] up [by herself] and, she [R #1] screamed and scared [CNA #6] and she put her back down. It was unclear what happened to her [R #1] elbow. She [R #1] had a clavicle fracture, a spinal fracture, and a humeral fracture that was identified when she was taken to the ER. I couldn't wrap my arm around what happened [to R #1 to cause those injuries].
J. Record review of the facility Report on Investigation (undated) revealed, Findings- After reviewing camera footage, the incident with the lift on Tuesday [[DATE]] may have caused [R #1's] injury. Following the incident [on [DATE]], it appears [Name of R #1] no longer uses her arm throughout the day. Nurses recognized slight swelling after the injury and looked at it again next day [[DATE]] where there was more bruising and more swelling but only slightly. On [DATE] around 3:52 pm cameras show swelling is very apparent.
K. On [DATE] at 11:24 am, during an interview with the NP, she stated, We were doing watchful waiting (closely watching a patient's condition but not giving treatment unless symptoms appear or change) [for R #1 after her right arm injury] and it [R #1's arm] got worse and we sent her to the hospital. She [R #1] was sent out [to the ER] and I didn't know she expired. I think it [R #1's injury] escalated and I think they [facility nursing staff] said it [R #1's arm injury] opened and was bleeding. I thought a little watchful waiting without laying eyes on it [R #1's right arm injury] would be fine. In hindsight, she [R #1] should have been sent out [to the ER] sooner. An expectation would be they [facility nursing staff] would hopefully see that [R #1's injury becoming worse and notify the NP]. I don't think I pulled her [R #1's] shirt up [to see her arm during an assessment on [DATE]], that was my thing that I didn't do. NP confirmed R #1 should have been sent to the ER sooner than she was sent out. NP confirmed she did not perform a complete assessment of R #1's injured right arm on [DATE] and she should have.
L. On [DATE] at 5:50 pm, during an interview with an anonymous staff member, they stated, From the reports, I was told she [R #1] had an open fracture and they sent her to the ER. From what I understand, she [R #1] was in the sit to stand [chair] and she was pretty weak as it is. She [R #1] let go of her weight, this is what I understand because I was not there, she [R #1] let go of her weight and the sling caught her arm. She [R #1] said 'ouch' and they [nursing staff] set her [R #1] down and her arm started to swell. Unless she [R #1] really dropped her weight and wasn't set down right away, that would have to be a traumatic event. Even with her being so frail, her back being broken and the clavicle, unless she just dropped.
M. On [DATE] at 10:21 am, during an interview with Nursing Aide (NA) #1, she stated, I was in the solarium (a room with extensive areas of glass to admit sunlight) and she [R #1] was getting on the lift with [Name of CNA #1] and she was secured. Her [R #1's] arm came off the bar and [Name of CNA #1] sat her [R #1] down. She [R #1] complained of elbow pain, so we told [Name of RN #1].
N. On [DATE] at 11:54 am, during an interview with the Social Services Director (SSD), she stated, Initially, when we reviewed cameras, we were looking at angles in the solarium. The other view showed that when she [R #1] was being lifted, you can see a jolt and her [R #1] arm falls and that's what we could see resulting in the fracture. [Name of RN #1] said she told [Name of NP] the next day she [R #1] had elbow pain [on [DATE]], but she [NP] didn't really assess it [R #1's injured right arm]. I would have expected her [NP] to do a full assessment [of R #1 after R #1's arm injury] and it [NP's assessment of R #1] was a look and go. She [NP] did not assess it [R #1's injured right arm]. [Name of previous Director of Nursing (DON)] knew about the lift incident [resulting in R #1's right arm injury] and she [previous DON] didn't think it was a big deal. She [previous DON] wasn't made aware of anything [involving R #1] until we were sending her [R #1] to the hospital.
SERIOUS
(H)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to effectively manage pain for 1 (R #1) of 2 (R #'s 1 and 2) residents...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to effectively manage pain for 1 (R #1) of 2 (R #'s 1 and 2) residents reviewed for pain by not assessing for pain and providing pain treatment. This deficient practice likely resulted in R #1 experiencing significant (long) periods of pain without sufficient relief for a fractured arm.
The findings are:
A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses:
1. Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms like progressive breathlessness and cough)
2. Hypertension (high blood pressure)
3. Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart)
4. Pleural Effusion (fluid-filled space that surrounds the lungs)
5. Cyst of Kidney (fluid-filled pocket that can form inside your kidneys)
6. Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly)
7. Chronic Kidney Disease
8. Pulmonary Embolism (one of the pulmonary arteries in the lungs gets blocked by a blood clot)
9. Heart Failure
B. Record review of R #1's physician orders dated 02/17/23 revealed, Tylenol (Acetaminophen) Oral Tablet 325 MG (milligrams), Give 2 tablet by mouth every 6 hours as needed for mild pain/ elevated temp [temperature].
C. Record review of R #1's physician orders dated 04/22/23 revealed, traMADol HCl Oral Tablet
50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain.
D. Record review of R #1's progress notes dated 06/06/23 at 4:05 pm revealed, Was made aware by CNA (Certified Nursing Assistant) that resident [R #1] was having R [right] elbow pain with visible swelling. Assessed residents R [right] elbow, swelling evident, with 1x1 [1 inch by 1] skin tear and hematoma (bad bruise). [ .] Notified POA (Power Of Attorney) and PCP (Primary Care Physician) of incident.
E. Record review of R #1's MD progress notes completed by Nurse Practitioner (NP) dated 06/07/23 at 1:33 pm revealed, No concerns noted by staff admitted to LTC [Long Term Care] because she cannot safely care for herself at home. Musculoskeletal [relating to or denoting the musculature and skeleton together]: no gross bony deformities.
F. Record review of R #1's physician orders dated 06/08/23 at 7:04 am revealed, Send to ER [Emergency Room] for treatment and evaluation per doctor order. R #1 was sent to the ER via ambulance on 06/08/23.
G. Record review of R #1's Medical Doctor Progress Notes dated 06/08/23 at 3:46 pm revealed, Had injury to her [R #1's] right humerus (lower end of upper arm bone) during a transfer 2-3 days ago and had sudden pain in right upper arm, was able to use it albeit (although) painful, this morning 6/8/2023 elbow area was draining/bleeding bruised, and was sent to the ED [Emergency Department], was found to have a Humerus fracture and was sent to [Name of local trauma center] hospital for further care.
H. Record review of R #1's Pain Level Summary (Pain Assessment: 0-10 with 0 meaning no pain and 10 meaning most pain):
1. 06/06/23 at 4:04 pm: 9/10 pain level
2. 06/06/23 at 5:15 pm- 6/10 pain level
3. 06/08/23 at 3:30 am- 5/10 pain level
R #1 was not assessed for pain on 06/07/23.
I. Record review R #1's Medication Administration Record dated June 2023 revealed the following:
1. 06/06/23 at 3:59 pm- R #1 was administered 50 mg of Tramadol for pain.
2. 06/07/23: No pain medication administered
3. 06/08/23 at 3:30 am- R #1 was administered 50 mg of Tramadol for pain.
There is no evidence that any other pain medication was administered between 06/06/23 and 06/08/23.
J. On 07/11/23 at 4:18 pm, during an interview with R #1's daughter, she stated, They [facility] said she was doing ok and her elbow hurt and they were giving her medicine. She [R #1] was in horrible pain for two days. She [R #1] had two breaks in her arm.
K. On 07/12/23 at 10:00 am during an interview with Registered Nurse (RN) #1, she stated, When I talked to [R #1] that day [06/07/23], she [R #1] said she was still having pain and she was sore. I [RN #1] told her [R #1] that it didn't have to be in horrible pain for her to get medication. The swelling [to R #1's right arm] was consistent. I want to say I gave her [R #1] that [pain medication] on Wednesday [06/07/23]. Whatever the MAR said is what I gave. RN #1 confirmed that R #1's MAR for pain medication was blank on 06/07/23. RN #1 also confirmed she did not assess R #1 for pain, nor give R #1 pain medication on 06/07/23, and she should have.
L. On 07/12/23 at 11:27 am, during an interview with the Nurse Practitioner (NP), she stated she would expect nursing staff to assess R #1 for pain and manage R #1's pain during watchful waiting [an approach in which time is allowed to pass before medical intervention or therapy is used] after R #1 injured her right arm.
M. On 07/13/23 at 10:22 am during an interview with Nursing Aide (NA) #1, she stated, She [R #1] complained of elbow pain [on 06/07/23], so we told [Name of RN #1]. She [R #1] had cried the whole lunch because she didn't eat. The nurses tended to her [R #1] because she was complaining of elbow pain [on 06/07/23]. NA #1 confirmed she informed nursing staff that R #1 was experiencing pain on 06/07/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the provider, Director of Nursing (DON), and nurse managemen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the provider, Director of Nursing (DON), and nurse management team for 1 (R #2) of 1 (R #2) resident experiencing a new onset of pain. If the facility is not notifying the provider when there is a change of condition (onset of new pain), then the provider is unable to make decisions related to treatment and advocate for the resident's care.
The findings are:
A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE].
B. Record review of R #2's progress notes dated 07/11/23 at 6:36 am revealed, Patient [R #2] started complaining of both pain in both legs from the hip going downwards this morning around 0530 [am]. Tylonol [sic] 500 mg [milligrams] given to the patient but she still complains of pain. Day nurse notified to close monitor.
C. On 07/12/23 at 11:28 am during an interview with the Nurse Practitioner (NP), she confirmed that she was not notified of R #2's increased pain on 07/11/23 and she would expect to be notified of that.
D. On 07/12/23 at 5:17 pm during an interview with the current DON, she stated, When the pain medication was given [to R #2] at 6 [am] then they [facility nursing staff] should have followed up [with R #2. If it [R #2's Tylenol] still wasn't working, then [Name of NP] should have been notified. DON confirmed communication between staff and the provider for R #2's new pain was not done correctly.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #4 and R #5) of 2 (R #4 and R #5) residents reviewed by not prov...
Read full inspector narrative →
Based on observation and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #4 and R #5) of 2 (R #4 and R #5) residents reviewed by not providing residents who smoke an area to smoke prior to changing the facility to a non smoking facility. This deficient practice is likely to result in the resident's life style, personal choices, needs and preference not being met. The findings are:
Findings for Resident #4:
A. On 07/11/23 at 1:15 pm, during an observation a notice was posted in the facility hallway stating, facility will be a smoking free facility effective immediately due to non-compliance of policy and safety.
B. On 07/12/23 at 1:09 pm, during an interview with R #4, he stated he was made aware of facility updating smoking policy that facility was going to be a Non smoking facility. After the smoking policy had taken affect he made a decision to discharge due to not being able to smoke any longer on facility property. R #4 further stated he was offered nicotine patches, gum and lozenges. R #4 wanted to be able to continue to smoke.
Findings for Resident #5:
C. On 07/11/23 at 4:26 pm, during an interview with R #5, she stated Facility let resident know one evening that smoking policy had changed, and smoking was no longer permitted at facility. She stated that facility did offer either lozenges, patches, and/or gum to help with smoking urges; as well as allow residents to leave premises to smoke if desired.
D. On 07/11/23 at 3:23 pm, during an interview with Certified Nursing Assistant (CNA) #2, she stated that residents did complain of the changes made to the smoking policy. It was implemented immediately and administration did not offer any other smoking alternatives besides the option of signing themselves out to leave the premises to go smoke.
E. On 07/12/23 at 9:45 am, during an interview with Registered Nurse (RN) #1, she stated she was made aware that facility is no longer a smoking facility which was made effective immediately, unknown to staff as to why the facility changed their policy. She stated that residents that smoked were offered no alternatives to help alleviate smoking cessations. RN #1 further stated that R #5 was annoyed by that policy. She is not aware of any smoking assessments being completed for residents who smoke, and staff were unable to determine if resident is a safe smoker because assessments are not completed.
F. On 07/12/23 at 5:45 pm, during an interview with the Assistant Administrator (AA), she stated the non-smoking policy was implemented in June of 2023 due to residents and staff practicing unsafe smoking by throwing cigarette butts in the grass, trash cans, and next to a propane tank. Residents and staff are allowed to leave the premises if they wish to continue to smoke. AA confirmed smoking assessments were not completed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a resident smoking assessment for 2 (R #s 4 and 5) of 2 (R ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a resident smoking assessment for 2 (R #s 4 and 5) of 2 (R #s 4 and 5) residents reviewed for assessments. This deficient practice is likely to result in residents being at risk for smoking related injuries.
The findings are:
Findings for Resident #4:
A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE].
B. Record review of R #4's care plan dated 11/08/21 revealed facility did identify resident as a smoker and implemented goals and interventions.
C. Record review of R #4's assessments revealed facility did not complete a smoking assessment for R #4.
D. On 07/12/23 at 9:45 am, during an interview with Registered Nurse (RN) #1, when asked how the facility determines if the resident is a safe smoker or needs supervision, RN #1 stated, You can't know if they're [residents] safe smokers if one [smoking assessment] is not done. I think we do need the [smoking] assessments [for residents]. RN #1 confirmed R #4 did not have a smoking assessment completed; and R #4 should have had a smoking assessment completed to determine if they were safe smoker or if R #4 needed facility assistance.
E. On 07/12/23 at 11:02 am, during an interview with the Social Services Director (SSD), she stated that nursing staff or a physician should have completed smoking assessment for R #4 and a smoking assessment for R #4 was not completed.
F. On 07/12/23 at 12:00 pm, during an interview with the Nurse Practitioner (NP), she stated a smoking assessment was not completed for R #4.
G. On 07/12/23 at 5:45 pm during an interview with the Assistant Administrator (AADM), she stated a smoking assessment was not completed for R #4 and should have been.
Findings for Resident #5:
H. On 07/11/2023 at 4:26 pm, during interview with R #5, when asked, how she is doing now that facility has a nonsmoking facility. R #5 stated smoking cessation (quitting smoking) was not easy to adjust when it first occurred.
I. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE].
J. Record review of R #5's assessments revealed that a smoking assessment was not completed for R #5.
K. On 7/12/23 at 12:00 pm, during an interview with the NP, she confirmed a smoking assessment was not completed for R #5, and should have been.
L. On 07/12/23 at 5:45 pm during an interview with the Assistant Administrator (AA), she confirmed Smoking assessments was not completed for R #5, but should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that 3 (R #'s 2, 3, and 6) of 6 (R #'s 2, 3, 4, 5, 6, and 7)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that 3 (R #'s 2, 3, and 6) of 6 (R #'s 2, 3, 4, 5, 6, and 7) residents were seen by the attending physician in the facility at least once a year. This deficient practice is likely to result in residents not receiving the required medical assessment and review resulting in resident receiving less than optimal care.
The findings are:
For Resident #2:
A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE].
B. Record review of R #2's Miscellaneous Page located in the Electronic Health Record (EHR) revealed R #2's last History and Physical assessment was completed on 01/26/20.
For Resident #3:
C. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE].
D. Record review of R #3's Miscellaneous Page located in the Electronic Health Record (EHR) revealed R #3's last History and Physical assessment was completed on 01/26/20.
For Resident #6:
E. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE].
F. Record review of R #6's Miscellaneous Page located in the Electronic Health Record (EHR) revealed R #6's last History and Physical assessment was completed on 06/11/20.
G. On 07/13/23 at 2:31 pm during an interview with the Nurse Practitioner (NP), she stated, I haven't done an official History and Physical [assessment for R #'s 2, 3, and 6]. NP confirmed a yearly History and Physical assessment was not completed for R #'s 2, 3, and 6 and should have been done.
H. On 07/13/23 at 2:32 pm during an interview with the Assistant Administrator (AADM), she confirmed R #'s 2, 3, and 6 did not have a yearly History and Physical assessment completed and they should have been done.
Feb 2023
12 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0740
(Tag F0740)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that 1 (R #30) of 1 (R #30) resident reviewed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that 1 (R #30) of 1 (R #30) resident reviewed was receiving the necessary behavioral health care services to meet the residents needs. This deficient practice likely resulted in resident not getting the care and assistance he needed, resulting in R #30 assaulting a staff member and being transferred to jail. The findings are:
A. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE] with the following psychiatric diagnoses:
1. MAJOR DEPRESSIVE DISORDER
2. BORDERLINE PERSONALITY DISORDER
3. MILD COGNITIVE IMPAIRMENT (the stage between the expected decline in memory and thinking that happens with age)
B. Record review of care plan date (OVERDUE) revealed the following:
1. Focus: The resident uses antidepressant medication r/t (related to) Depression. Interventions: Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts,withdrawal .
2. Focus: The resident uses psychotropic medications r/t Disease process. Interventions:PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's,social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Monitor/record occurrence of for target behavior symptoms pacing,wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol.
Focus: The resident is/has potential to be verbally aggressive r/t Poor impulse control. Interventions:
C. Record review of R #30's Progress Notes dated 07/20/22 revealed, [Name of R #30], DON [Director of Nursing], and myself met with [Name of R #30] to go over a letter he left on my desk,(His medication bill). He wrote a note on it 'Do not give this to me again'. I explained to him that it was his prescription bill that the pharmacy sent him, he was angry about the bill. I told him, I would contact the pharmacy for him. [ .] He [R #30] started to get very angry and began yelling at me. [Name of DON] asked him to calm down, he stated he just gets so frustrated. He requested to be seen by a professional because he feels himself being more frustrated than usual and he stated that his Asperger's [a developmental disorder affecting ability to effectively socialize and communicate] is really bothering him and would really like to see a professional that could help him with it. We let [Name of R #30] know we would work on getting him help.
D. Record review of R #30's Progress Notes dated 07/22/22 revealed, Notified by activities that resident [R #30] requested to herself and DON, [Name of DON], that he wanted go to [Name of Psychiatric Services/Behavioral Health Provider] to get his medication evaluated. Spoke with PCP [Primary Care Physician] regarding request. New order received.
E. Record review of R #30's physician orders dated 07/22/22 revealed, Referral for [Name of Psychiatric Services/Behavioral Health Provider] for medication evaluation per resident request/PCP approval.
F. Record review of the facilities communication report with Psychiatric Services/Behavioral Health Provider for R #30 was dated 07/25/22 at 2:36 pm. This indicated the facilities first attempt to refer R #30 for psychiatric services per physician order did not occur until 3 days after order was provided. Report revealed, 07/27/22- 9:27 am: Needed updated notes- didn't accept referral. Would need to be suicidal, homicidal, hallucinations. [Name of Psychiatric Services/Behavioral Health Provider] won't consider in patient or crisis. [Name of R #30] needs to get him a therapist or psychiatrist to have them send referral, Emergency Room.
G. On 02/28/23 at 12:21 pm during an interview with the DON, she stated, We [facility] were trying to get him [R #30] to [Name of Psychiatric Services/Behavioral Health Provider] and they [Psychiatric Services/Behavioral Health Provider] said he [R #30] didn't meet the criteria [to be admitted into the Psychiatric Services/Behavioral Health Provider]. We [facility] tried multiple different places. We tried [name of behavioral health provider and name of name of Psychiatric Serves/Behavioral Health Provider] on 07/25/22, and both places refused to admit R #30.
H. Record review of R #30's Progress Notes dated 07/26/22 at 8:11 am revealed, At approximately 0710 [am], Resident [R #30] approached Housekeeping Personnel, [Name of Housekeeper (HK) #1]. and got real close to her and started yelling at her. 'I have something to say to you. I want you to when I'm in on the commode you came and Knock, Knock, Knock. [sic] What the hell is wrong with you. You can't rush a bowel movement.' House Keeper Attempted to say 'I'm' but the resident stated: 'its not something to laugh about, Bitch.' He [R #30] grabbed her [HK #1] duster and hit her twice on the forehead, left temple area and positioned the handle across her neck and pushed her against the wall twice. This nurse intervened and took the duster away from resident so Housekeeper could be safe. He [R #30] stayed and cont. [continued] to curse and yell at her, spitting on her. After he finally stopped yelling, the Housekeeper walked away, per this nurses instruction. Res [Resident] stayed in hall way and stated; 'I waited 2 days to do this.' and then he walked away.
I. On 02/28/23 at 1:11 pm during an interview with the Interim Administrator (IA), he stated, When asked if he was aware of any issue prior to the 07/26/22, IA stated. He's [R #30] yelled at people before. I wasn't aware of anything [R #30's behaviors/psychiatric services request] until the investigation. If there are indications or signs of something that he [R #30] was agitated, then yes [expects R #30 to be sent to the emergency room (ER) so R #30 can be referred to Psychiatric Services/Behavioral Health Provider]. I'm not certain what steps [Name of DON] was making to move him [R #30 to the Psychiatric Services/Behavioral Health Provider]. There was evidence of escalation and we knew that was a problem. [R #30] did state he needed more [psychiatric] services. We never anticipated what did come out. IA confirmed he would expect the facility to provider services to R #30 as ordered by a physician. IA further confirmed that R #30 had been taken to jail by the police after the incident.
J. On 02/28/23 at 2:12 pm during an interview with the Social Services Director (SSD), she confirmed R #30 wanted to be transferred to a Psychiatric Services/Behavioral Health Provider located outside of the facility but R #30 needed a provider referral or ER referral before R #30 could be admitted into the Psychiatric Services/Behavioral Health Provider. SSD also confirmed the facility made initial contact with the Psychiatric Services/Behavioral Health Provider on 07/25/22.
K. On 02/28/23 at 3:14 pm during an interview with the Facility Nurse Practioner (FNP), she confirmed R #30 was having increased psychiatric behaviors and she wanted him to be sent to the Psychiatric Services/Behavioral Health Provider as soon as possible. FNP stated, Mostly, I wanted him [R #30] to have a behavioral health evaluation. He [R #30] seemed paranoid and had delusions and thoughts about things. I knew getting into a behavioral health facility is challenging. FNP stated she wrote an order when she found out R #30 was having an increase in behaviors (07/22/22) and she would expect the facility to follow physician orders [referring to finding F] in a timely manner.
L. On 02/28/23 at 4:49 pm during an interview with the DON, she stated, When he [R #30] came and talked to me and [Name of SSD], he [R #30] was not having a melt down at that time. He [R #30] just wanted to be re-evaluated for his medication. We called [Name of FNP] and let her know what was needed. He [R #30] was coming to us like he needed additional medication and he said he wasn't going to hurt anyone. I didn't think it [R #30's psychiatric behaviors] were that bad. We should have gone the hospital route (sent him to the hospital when he started showing behaviors) but, by the time she got involved the police had been called and R #30 was taken to jail. DON confirmed R #30's physician orders for psychiatric service request should have been responded to in a more timely manner. DON further stated that R#30 would not be allowed to return to the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report and provide follow up report within 5 working days from the date of the incidents to the State Survey Agency, for 1 (R #30) of 1 (R ...
Read full inspector narrative →
Based on record review and interview, the facility failed to report and provide follow up report within 5 working days from the date of the incidents to the State Survey Agency, for 1 (R #30) of 1 (R #30) residents reviewed for incidents. If the facility fails to provide a 5 day follow-up report to the State Agency, then the State Agency will be unable to assure residents are safe and have a hazard free environment.
B. Record review of Facility Incident Report dated 07/26/22 revealed, Resident [R #30] approached housekeeper and began to shout at her. He [R #30] pulled her broom duster from her hands and attempted to choke her while slamming her head into wall. An initial incident report was sent to the State Agency but no 5-day follow up report was submitted for the incident
C. On 02/28/23 at 5:33 pm during an interview with the Director of Nursing (DON), she stated, No there wasn't one done [5-day follow up report for R #30's incident]. I thought I did one [5-day follow up report for R #30's incident]. DON confirmed a 5-day follow up report was not completed for R #30's incident and one should have been completed and submitted to the State Agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #30) of 2 (R #'s 29 and 30) residents reviewed for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #30) of 2 (R #'s 29 and 30) residents reviewed for discharges received written notice of transfer/discharge. If the facility does not give residents notice of discharge, residents are likely not to have the information to appeal a facility initiated transfer decision. The findings are:
A. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE] with the following psychiatric diagnoses:
1. MAJOR DEPRESSIVE DISORDER
2. BORDERLINE PERSONALITY DISORDER
3. MILD COGNITIVE IMPAIRMENT (a condition in which people have more memory or thinking problems than other people their age)
B. Record review of R #30's Progress Notes dated 07/27/22 at 11:43 am revealed, [AGE] year old male [R #30] admitted to [Name of Facility] on 11/16/2021. At the time of this note provider was notified of a physical altercation with the staff. He [R #30] was detained and removed from the facility at that time. He [R #30] has recently asked for Inpatient evaluation at [Name of Psychiatric Service Provider] for BH [Behavioral Health] management. He [R #30] has had increasingly paranoid thoughts and behaviors
C. Record review of R #30's Progress Notes dated 07/26/22 at 8:13 am revealed, [Name of Facility Nurse Practioner (FNP)] notified about aggressive behavior and He [R #30] is his own POA [Power Of Attorney].
D. On 02/28/23 at 1:09 pm during an interview with the Interim Administrator (IA), he stated. I was just told there was an incident with [Name of R #30]. [Name of R #30] had been arrested, the Police felt we needed to get him [R #30] out of the building. My main concern was that [Name of R #30] would be safe. We wanted to move him [R #30] to get a [Psych] evaluation done. The Police department really pushed for [R #30] going to jail instead of the hospital. It was viewed as an attack on the employee. To keep him [R #30] detained, it felt like the right thing to give him space and get him counseling. [Name of R #30] did comeback when he was released from the jail. We got a call that he [R #30] was released to his friend. [Name of DON] came here [to the facility] to make sure we could go through the process of discharge. As far as an official discharge, it wasn't a normal discharge.
E. On 02/28/23 at 2:10 pm during an interview with the Social Services Director (SSD), she stated, His [R #30's discharge] was a little different. He [R #30] was wanting to go to [Name of Psychiatric Service Provider] and they [Psychiatric Service Provider] refused him [R #30] because he needed an assessment in the emergency room (ER) or by a provider. He [R #30] was not able to come back to the facility due to the incident that happened on 07/26/22. He [R #30] was let go [from the facility]. SSD further stated that the facility had determined that they would not accept him back at the facility because of his behavior and they thought it would not be safe and no other discharge arrangements had been made for R#30.
F. Record review of the medical record for R #30 did not include a written transfer and discharge notice with all the required information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #30) of 2 (R #'s 29 and 30) residents reviewed for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #30) of 2 (R #'s 29 and 30) residents reviewed for discharges was able to return to the facility after having a change in behavior that required treatment, unless the resident was evaluated after treatment had been received and the facility determined that they could not meet the resident's needs. This deficient practice likely resulted in R #30 not receiving a safe and appropriate discharge. The findings are:
A. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE] with the following psychiatric diagnoses:
1. MAJOR DEPRESSIVE DISORDER
2. BORDERLINE PERSONALITY DISORDER
3. MILD COGNITIVE IMPAIRMENT (a condition in which people have more memory or thinking problems than other people their age)
B. Record review of R #30's Progress Notes dated 07/27/22 at 11:43 am revealed, [AGE] year old male [R #30] admitted to [Name of Facility] on 11/16/2021. At the time of this note provider was notified of a physical altercation with the staff. He [R #30] was detained and removed from the facility at that time. He [R #30] has recently asked for Inpatient evaluation at [Name of Psychiatric Service Provider] for BH [Behavioral Health] management. He [R #30] has had increasingly paranoid thoughts and behaviors
C. Record review of R #30's Progress Notes dated 07/26/22 at 8:13 am revealed, [Name of Facility Nurse Practioner (FNP)] notified about aggressive behavior and He [R #30] is his own POA [Power Of Attorney].
D. Record review of R #30's Progress Notes dated 07/26/22 at 3:28 pm revealed, Ombudsman and [Name of State Agency] contacted to report incident from this morning. Was advised if resident [R #30] was a safety risk to staff and residents he would not be able to return to facility. Will work with appropriate entities to help find future placement.
E. On 02/28/23 at 1:09 pm during an interview with the Interim Administrator (IA), he stated. I was just told there was an incident with [Name of R #30]. [Name of R #30] had been arrested, the Police felt we needed to get him [R #30] out of the building. My main concern was that [Name of R #30] would be safe. We wanted to move him [R #30] to get a [Psych] evaluation done. The Police department really pushed for that [R #30] going to jail instead of the hospital. It was viewed as an attack on the employee. To keep him [R #30] detained, it felt like the right thing to give him space and get him counseling. [Name of R #30] did comeback when he was released from the jail. We got a call that he [R #30] was released to his friend. [Name of DON] came here [to the facility] to make sure we could go through the process of discharge. As far as an official discharge, it wasn't a normal discharge.
F. On 02/28/23 at 2:10 pm during an interview with the Social Services Director (SSD), she stated, His [R #30's discharge] was a little different. He [R #30] was wanting to go to [Name of Psychiatric Service Provider] and they [Psychiatric Service Provider] refused him [R #30] because he needed an assessment in the emergency room (ER) or by a provider. He [R #30] was not able to come back to the facility due to the incident that happened on 07/26/22. He [R #30] was let go [from the facility]. SSD further stated that the facility had determined that they would not accept him back at the facility because of his behavior and they thought it would not be safe and no other discharge arrangements had been made for R#30.
G. On 02/28/23 at 4:47 pm during an interview with the DON confirmed that R #30 should have been safely discharged to the ER and not jail. DON also confirmed R #30 was not safely discharged from the facility after his release from jail and should have been. DON stated that R #30 was not going to be allowed to return to the facility because of his behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #27) of 1 (R #27) residents reviewed for Minimum D...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #27) of 1 (R #27) residents reviewed for Minimum Data Set (MDS) assessments, had MDS documents completed, submitted and finalized in a timely manner (after her discharge). If MDS assessments are not completed and submitted in a timely manner, then residents are likely to receive less than optimal care. The findings are:
A. Record review of R #27's face sheet revealed R #27 was admitted into the facility on [DATE].
B. Record review of R #27's MDS Page located in R #27's Electronic Health Record (EHR) revealed R #27's latest completed and submitted MDS assessment was the Quarterly Review dated 10/12/22.
C. On 02/28/23 at 9:49 am during an interview with the Director of Nursing (DON), confirmed R #27 was discharged from the facility on 11/15/22 and did not return .
D. On 02/28/23 at 2:28 pm during an interview with the Minimum Data Set Coordinator (MDSC), she stated, I think she [R #27] went home and passed away. If I recall correctly, she [R #27] was discharged . She [R #27] should of had one [discharge MDS completed and submitted]. MDSC confirmed a discharged MDS for R #27 should have been completed and submitted, and it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan tha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that reflects anticoagulant use (medication used to prevent blood clots) for 1 (R #8) of 1 (R #8) residents reviewed. Failure to develop and implement a resident centered care plan may result in staff's inability to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are:
A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE].
B. Record review of R #8's physician orders dated 10/12/22 revealed, Warfarin Sodium Tablet [anticioagulant] 7.5 MG [milligram].
C. Record review of R #8's Care Plan dated 01/25/23 revealed no care plan for anticoagulant use.
D. On 02/28/23 at 5:30 pm during an interview with the Director of Nursing (DON), she confirmed anticoagulant use for R #8 was not care planned and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the attending physicians reviewed and responded to pharmacy recommendations for 6 residents [R #2, 9, 10, 12, 14, 16] of 7 residents ...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure the attending physicians reviewed and responded to pharmacy recommendations for 6 residents [R #2, 9, 10, 12, 14, 16] of 7 residents [R #2, 8, 9, 10, 12, 14, 16] reviewed for Gradual Dose Reductions. If consultant pharmacist recommendations are not reviewed by physicians and orders are not implemented on time, residents are likely to continue taking medications they do not need, or potentially experience unnecessary drug interactions or adverse side effects.
The findings for R #2:
A. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations:
On 05/19/22 pharmacist's recommendation for R #2 stated Please review Lorazepam [used to treat anxiety disorders] therapy for Gradual Dose Reduction (GDR). This document was not responded to or signed by the physician until 11/11/22.
Findings for R #9:
B. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations:
On 05/19/22 pharmacist's recommendation for R #9 stated Please review Mirtazapine [used to treat depression] therapy for Gradual Dose Reduction [GDR]. This document was not responded to or signed by the physician until 11/11/22.
The findings for R #10 are:
C. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations:
On 05/19/22 pharmacist's recommendation for R #10 stated. Please review Mirtazapine [used to treat depression] therapy for Gradual Dose Reduction [GDR]. This document was not responded to or signed by the physician until 11/11/22.
The findings for R #12 are:
D. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations:
On 05/19/22 pharmacist's recommendation for R #10 stated Please review Sertraline therapy [used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder] therapy for Gradual Dose Reduction [GDR]. This document was not responded to or signed by the physician until 11/11/22.
The findings for R #14 are:
E. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations:
On 05/19/22 pharmacist's recommendation for R #14 stated Please review Duloxetine therapy therapy [used to treat depression and anxiety] therapy for Gradual Dose Reduction [GDR]. This document was not responded to or signed by the physician until 11/11/22.
The findings for R #16 are:
F. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations:
On 05/19/22 pharmacist's recommendation for R #16 stated Please review Sertraline therapy [used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder] therapy for Gradual Dose Reduction [GDR]. This document was not responded to or signed by the physician until 11/11/22.
G. On 02/28/23 at 5:3 during an interview with DON when asked why the pharmacist recommendations for the GDR's were not signed off until 11/11/22 for R #2, 9,10,12,14, &16 since the recommendations were made on 05/19/22 during the pharmacist visit. DON responded that another staff member was tasked with faxing them to the provider and she was not aware of when they were actually faxed to the Physician. DON further acknowledged that there was not a system in place for tracking when they come back from the provider or when they were sent to the provider. DON stated that the recommendations should be sent to the Physician as soon as they are received by the facility to ensure that the residents are given the proper dosages of medication.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to meet professional standards of quality care for 2 (R #'s 8 and 14) of 2 (R #'s 8 and 14) residents reviewed by:
1. Not ensurin...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to meet professional standards of quality care for 2 (R #'s 8 and 14) of 2 (R #'s 8 and 14) residents reviewed by:
1. Not ensuring there was an order to monitor a resident that is on an anticoagulant (R #8)
1. Not administering Oxygen (O2) in accordance with the physician's orders for R #14.
If the facility is not administering oxygen as prescribed, or monitoring residents on anticoagulants then residents are likely to not get the therapeutic results as needed.
The findings are:
The findings for R #8 are:
A. Record review of physicians orders dated 10/12/22 revealed the following order: Warfarin Soduim [used to treat blood clots and/or to prevent new clots from forming in your body] 7.5 mg [milligrams] one tablet by mouth every evening.
B. On 02/28/23 at 5:57 pm during a phone interview with Physician (P) #1, Physician reviewed the chart and confirmed that there was no order to monitor PT/INR levels (Prothrombin Time Test/international normalized ratio- measures the time it takes for a clot to form in a blood sample and INR is a calculation based on the results). She further stated that she needed to write an order to monitor the PT/INR. When asked what the appropriate action would be if the resident had a high level of Warfarin in the blood, P #1 stated I would adjust it (medication dose).
C. Record review of R #8's lab work revealed that labwork consistent with monitoring Warfarin Levels in the blood: PT [Protimee-measures how fast blood clots) and INR (ratio) were obtained on 11/16/22. PT: 35.4 seconds indicates a high level. (normal range is 11.5-13.5 seconds) INR: 3.0 Ratio indicates a high level (normal range is 0.8-1.2)
D. Record review of R #8's lab work also revealed that the most recent labs were obtained on 01/13/23 at 7:30 am with the following results: PT 24.4 seconds a high reading with a normal range of 9.1-14.9 seconds.
E. On 02/28/23 at 5:30 pm during an interview with DON (Director of Nursing) when asked what was done in response to the labs obtained, DON stated. Its based on the providers recommendations. When asked how often R #8's Warfarin levels were being monitored DON responded I remember talking to the pharmacist about it; but I am not sure what the recommendation was. DON reviewed chart and confirmed that there were no physician orders to monitor Warfarin levels.
R #14 Findings:
F. Record review of physician's order dated 02/27/23, indicated keep O2 oxygen > (greater than) 90%. Via nasal cannula (A device used to deliver supplemental oxygen to a patient in need of respiratory help).
G. Record review of R #14 Face Sheet revealed: Diagnoses: Chronic Obstructive Pulmonary Disease (COPD) with (ACUTE) Exacerbation, other Asthma (A group of lung diseases that block airflow and make it difficult to breathe).
H. Record Review of R #14 Care Plan dated 11/17/22 revealed: Emphysema (A disorder affecting the alveoli (tiny air sacs) of the lungs) /COPD, Oxygen settings: O2 via nasal prongs at 4 L (liters) continuously Humidified (to make air humid or damp).
I. On 02/27/23 at 10:38 am during an observation R #14's oxygen concentrator was set at 4 and a half liters, and tubing was not labeled and dated. Humidifier was empty.
J. On 02/27/23 at 4:38 pm during an observation of oxygen concentrator humidifier bottle was observed to be empty during an interview with Certified Nursing Assistant (CNA), he stated that the Oxygen tubing was not labeled or dated. He also confirmed that the humidifier was empty.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to:
1. Ensure narcotic medications (regulate medications-perception-altering or sensory-dulling medications) are properly documented after medic...
Read full inspector narrative →
Based on observation and interview, the facility failed to:
1. Ensure narcotic medications (regulate medications-perception-altering or sensory-dulling medications) are properly documented after medication administration.
2. Ensure medication storage room is kept at the appropriate temperature (68-77 degrees Fahrenheit)
These deficient practices are likely to negatively impact the health of all 26 residents listed on the census provided by the Director of Nursing (DON) on 02/27/23.
A. On 02/28/23 at 9:15 am during review of the narcotic medication log and the medication bubble pack (medication card that holds all the medication and is numbered) it was observed that the medication Hydrocodone-APAP 5-325 (medication used to treat pain) for R #1 was documented in the log book as having 22 tablets left in the bubble pack and review of the bubble pack revealed that there were 21 tablets in the bubble pack.
B. On 02/28/23 at 9:16 am during an interview with Registered Nurse (RN) #1, she stated that the medication in the bubble pack and the narcotic log book did not match. The medication had been administered during morning medication administration and had not been documented as given and should have been signed out in the narcotic log book.
Finding for Medication Storage Room:
C. Record review of Room Temperature log for February 1, 2023 to February 27, 2023 revealed temperature range from 76 degrees to 83 degrees.
D. On 02/28/23 at 9:16 am during observation of the medication room the temperature was observed to be at 83 degrees Fahrenheit. Observed were the following medications that indicated they should be stored at room temperature between 68 and 77 degrees Fahrenheit:
2 tubes of Diclofenac Sodium topical gel (medication used to treat inflammation) 100 g (grams)
1 Betamethasone Valerate ointment (used to treat skin conditions)
1 Triamciolone Acetonide Cream 0.1% (used to treat skin conditions)
2 boxes Budesonide Inhalation suspension (used to help prevent the symptoms of asthma) 0.5 mg/2 ml (militers)
1 box Symbicort 120 inhalations (used to treat asthma)
1 box Albuterol Sulfate inhalation aerosol HFa (used to relieve cough, wheezing and trouble breathing by increasing the flow of air through the bronchial tubes) 90 mcg (micrograms)
1 box Albuterol Sulfate inhalation solution .083% 2.5/3 ml
4 bottles of Polyethlene Glycol (used to treat occasional constipation) 8.3 oz bottles
2 bottles of Mylanta (used to help relieve the symptoms of heartburn, acid reflux, and gas)12 fl (fluid) oz (ounces)
E. On 02/28/23 at 9:48 am during an interview with the Director of Nursing, she stated. The temperature in the medication room has been an issue, we had 2 small coolers in there to keep it cool. Prior to just a few minutes ago I did not know the coolers were no longer working. A work order should have been put in when it was discovered they were no longer working. I do agree it is too hot in the med (medication) room. DON further stated that all the above medication was ordered and to be administered to residents that were still in the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
Based on interview the facility failed to submit accurate direct care staffing information to CMS (Centers for Medicare Services). This deficient practice is likely to result in inaccurate direct care...
Read full inspector narrative →
Based on interview the facility failed to submit accurate direct care staffing information to CMS (Centers for Medicare Services). This deficient practice is likely to result in inaccurate direct care staffing information for residents/facility. The findings are:
A. On 02/28/23 at 12:40 PM during an interview with the Director of Nursing (DON) when asked if there was 24 hour licensed nursing coverage and sufficient weekend staffing due to the triggered Payroll Based Journal (PBJ) Staffing Data Report she stated yes. The inaccurate staffing totals on the PBJ Report were due to the incorrect data entry. The errors were for the Fiscal Year Quarter 4 2022, July 1 - September 30.
B. On 02/28/23 at 12:50 PM during an interview with the Lab Clerk, she stated that she is the person who is responsible for entering the data for the PBJ report. She further stated that she did not know all the positions of the agency nurses if they were Registered Nurses (RN's) or Licensed Practical Nurses (LPN's) and that she was also including the dietary staff in the PBJ as part of the nursing direct care staff because she thought that dietary staff provided the meal service to residents (delivering trays) were considered feeding assistants. She was not sure how and what staff was to be entered in the system and once the system is locked you can't go back and change it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to store foods under sanitary conditions by not:
1. Ensuring food items in the refrigerator and freezer were properly labeled and dated.
2. Ensu...
Read full inspector narrative →
Based on observation and interview, the facility failed to store foods under sanitary conditions by not:
1. Ensuring food items in the refrigerator and freezer were properly labeled and dated.
2. Ensuring food items in the refrigerator and freezer are properly covered.
3. Ensuring used oil was covered appropriately, labeled, and dated in the dry storage.
These deficient practices are likely to affect all 26 residents listed on the resident census list provided by the Director of Nursing (DON) on 02/17/23, and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.
The findings are:
A. On 02/27/23 at 9:52 am during the initial tour of facility kitchen, the following was observed in the kitchen freezers, kitchen refrigerators, and kitchen dry storage:
1. 3- plastic storage bags of rolls was not labeled or dated and stored in the refrigerator.
2. 1- baked potato wrapped in aluminum foil was not labeled or dated and stored in the refrigerator.
3. 1- 37.05 ounce (oz) Sysco Classic Golden Grill Hash brown potatoes carton was left open to air and stored in the kitchen refrigerator.
4. Several pieces of chicken wrapped together in plastic wrap was not labeled or dated and stored in the freezer #1.
5. 1- large plastic bag of meatballs was not labeled or dated and stored in freezer #2.
6. 1- large metal pan of oil with aluminum foil loosely covering it was not labeled or dated and stored in the dry storage.
B. On 02/27/23 at 10:13 am during an interview with the Dietary Manager (DM), he confirmed all findings and stated, If [food/beverage items] it's out of the original packaging then it [food/beverage items] should be labeled and dated. DM also stated that all food/beverage items should be labeled, dated, and stored appropriately.
C. On 02/28/23 at 11:31 am during an follow up kitchen observation, the following was observed:
Freezer #1:
1. 1- 11 pound (lb) box of Beyond Sausage was left open to air and stored in freezer #1.
D. On 02/28/23 at 11:35 am during an interview with the DM, he confirmed the additional finding and stated food should not be left open to air.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to have a qualified, trained, or appropriately certified Infection Control Nurse designated as the Infection Preventionist (IP) affecting all ...
Read full inspector narrative →
Based on record review and interview, the facility failed to have a qualified, trained, or appropriately certified Infection Control Nurse designated as the Infection Preventionist (IP) affecting all 26 residents identified on the resident census list provided by the Director of Nursing (DON) on 02/27/23. This deficient practice is likely to result in residents being at greater risk of infectious disease. The findings are:
A. Record review of the IP's Infection Control and Prevention Certificate of Completion- 4.0 Credit Hours dated 06/28/22 revealed the certificate was not obtained from an approved source. The certificate was issued by New York State Department of health.
B. On 02/28/23 at 2:21 pm during an interview with the IP, she stated, I didn't know I needed it [Infection Control and Prevention Certificate]. Nobody ever told me about that one [approved Infection Control and Prevention Infection Preventionist Certificate].
C. On 02/28/23 at 4:50 pm during an interview with the Director of Nursing (DON), she stated, [Name of the Facility Human Resources Staff] and I just spoke about this [IP's current non-State Agency approved Infection Control and Prevention Certificate] last week. DON confirmed the facility IP should have the State Agency approved Infection Control and Prevention Certificate and the IP does not.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New Mexico facilities.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s). Review inspection reports carefully.
- • 30 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade F (35/100). Below average facility with significant concerns.
- • 85% turnover. Very high, 37 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Colfax General Ltc's CMS Rating?
CMS assigns Colfax General LTC an overall rating of 3 out of 5 stars, which is considered average nationally. Within New Mexico, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Colfax General Ltc Staffed?
CMS rates Colfax General LTC's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 85%, which is 38 percentage points above the New Mexico average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 75%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Colfax General Ltc?
State health inspectors documented 30 deficiencies at Colfax General LTC during 2023 to 2025. These included: 3 that caused actual resident harm and 27 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Colfax General Ltc?
Colfax General LTC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 34 certified beds and approximately 31 residents (about 91% occupancy), it is a smaller facility located in SPRINGER, New Mexico.
How Does Colfax General Ltc Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, Colfax General LTC's overall rating (3 stars) is above the state average of 2.9, staff turnover (85%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Colfax General Ltc?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Colfax General Ltc Safe?
Based on CMS inspection data, Colfax General LTC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in New Mexico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Colfax General Ltc Stick Around?
Staff turnover at Colfax General LTC is high. At 85%, the facility is 38 percentage points above the New Mexico average of 46%. Registered Nurse turnover is particularly concerning at 75%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Colfax General Ltc Ever Fined?
Colfax General LTC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Colfax General Ltc on Any Federal Watch List?
Colfax General LTC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.