A list of the most recent deficiencies for Colfax General Ltc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-19 | 2024-02-16 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-19 | 2024-02-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-19 | 2024-02-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-23 | 2024-02-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-23 | 2024-02-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-13 | 2023-08-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-13 | 2023-08-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-13 | 2023-08-04 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-13 | 2023-08-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-13 | 2023-08-04 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-07-13 | 2023-08-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-28 | 2023-04-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-28 | 2023-04-21 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-28 | 2023-04-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-28 | 2023-04-21 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-02-28 | 2023-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-28 | 2023-04-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-28 | 2023-04-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-28 | 2023-04-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-28 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-28 | 2023-04-21 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-02-28 | 2023-04-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-02-28 | 2023-04-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-02 | 2023-04-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-02 | 2023-04-20 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-03-02 | 2023-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-04-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-02 | 2023-04-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-02 | 2023-04-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-01 | 2022-03-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-01 | 2022-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-01 | 2022-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-01 | 2022-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-02 | 2022-02-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-02 | 2022-02-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-02 | 2022-02-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-02 | 2022-02-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-02 | 2022-02-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-02 | 2022-02-17 | N |
