Colfax Health and Rehabilitation: Fire Hazard Violations - WA

Federal inspectors found 50 cigarette butts mixed with paper and surgical masks in a plastic garbage bin by the front door of Colfax Health and Rehabilitation of Cascadia during a July inspection. Multiple cigarette butts lay in brown, brittle grass around the facility sign, along the driveway fence, and under a facility window.

The dangerous conditions prompted an immediate jeopardy citation — the most serious violation possible — after inspectors discovered the facility had no safe disposal method for cigarette butts and failed to complete required smoking assessments for residents.

One resident was observed leaning against a telephone pole at the top of the facility driveway smoking at 8:28 AM on July 10. Another resident sat on their walker at the end of the driveway smoking that afternoon while cigarette butts littered the surrounding area.

The Washington State Department of Natural Resources had issued a high fire danger warning that day. An extreme heat warning was also in effect.

When asked about the fire risk from improperly disposed cigarette butts, the director of nursing admitted residents needed to dispose of cigarettes safely but said "they did not have a means to do that."

The facility's smoking policy required residents who smoked to have safety assessments completed to determine supervision levels and interventions to prevent injury. But inspectors found multiple residents smoking without proper evaluations.

Resident 22 had been found smoking outside in March and told by staff that smoking wasn't allowed on the property. A social services director documented that the resident "wouldn't give their lighter to Staff E for safe keeping."

Four months later, the resident still had cigarettes and a lighter in their bag. During an interview, they removed both items and showed them to inspectors. No smoking evaluation had ever been completed despite the March incident.

The resident was taking Varenicline Tartrate daily to decrease tobacco craving and had been determined by staff to be "dependent and unsafe to smoke." Their care plan stated they "could not smoke while at the facility."

Staff acknowledged the resident should have had a smoking evaluation and safety plan completed in March when they were first identified as a smoker.

The facility also failed to provide adequate nutrition monitoring and respiratory care. Resident 1 was supposed to be weighed weekly according to their nutritional care plan due to diagnoses including dementia and malnutrition. When the dietitian requested a reweigh after documenting a suspicious 19.4-pound weight gain in 16 days, staff waited almost a month to comply.

The resident's weight dropped from 129.4 pounds to 105.6 pounds during that period, then fell to 94 pounds by May. The dietitian had requested the reweigh because the initial weight was "believed to be an error."

Resident 17 lost 12.89% of their body weight over six months, experiencing nausea and refusing meals after testing positive for COVID-19. The resident was hospitalized for weakness and nausea, but their physician was never notified of the condition changes.

"If I would have been notified, I would have ordered labs and possibly changed the resident's medications," the doctor told inspectors. "I felt the nausea had impacted the resident's weight."

The facility failed to follow a dietitian's recommendation to add margarine or sugar to the resident's meals to promote adequate intake.

Oxygen equipment posed additional safety risks. Four residents requiring oxygen therapy had dirty, dust-covered filters on their concentrators. One resident's oxygen filter cover was found lying on the floor, with the filter and storage area coated in thick dust.

Resident 39's personal oxygen concentrator was empty on multiple occasions. The resident stated they "could not feel any air" but denied shortness of breath. Orders for the resident's oxygen therapy failed to specify the number of liters needed.

Resident 16 used oxygen at night for about two weeks without any physician order. Staff provided the equipment after a hospital stay in June, but no order was documented until July 11 — more than a month later.

The facility's oxygen therapy policy required orders to be verified before initiating treatment and disposable equipment to be changed routinely per manufacturer directives.

Pain management failures left Resident 294 in constant severe pain. The quadriplegic resident consistently reported pain levels of 7 to 9 out of 10, stating their pain medications weren't lasting and "sometimes it works and sometimes it doesn't."

The resident was prescribed Oxycodone every six hours as needed and Baclofen every eight hours as needed, but staff failed to document when non-pharmacological interventions were provided. The resident complained that staff left them in bed overnight without repositioning assistance.

"They were all over-worked... you can hear the buzzers going off constantly," the resident said about staffing levels.

Records showed no repositioning documentation after 8 PM for 13 days and before 7 AM for 15 days during a 30-day review period. The resident desired to be at a pain level of 4 out of 10 but remained in severe pain throughout the inspection.

The director of nursing acknowledged that nursing staff should have documented that the resident's pain wasn't being managed and notified the physician.

Staffing violations compounded care problems. Two nursing assistants worked at the facility for months without proper certification — one since April and another since May. Both were observed providing direct resident care with only "pending" licenses in their personnel files.

Five staff members, including nurses and a cook, had not received required training on dementia and behavioral health despite caring for residents with those conditions.

Food safety violations in the kitchen included expired tortillas, macaroni salad, salsa, and strawberry yogurt. Open packages of berries weren't dated, celery sat uncovered in the refrigerator, and cooked eggs had no use-by dates.

A cook with a two-inch beard served food without a beard net during lunch service. The dietary manager stated they were told by a former dietitian that the beard was short enough not to require covering.

Infection control failures put all residents at risk when Resident 18 tested positive for COVID-19 at an outside clinic. Despite notification from the clinic, facility staff didn't implement required precautions for nearly two days.

Staff weren't wearing surgical masks as recommended by the county health department, and the resident wasn't placed in isolation until 27 hours after the positive test. The health department had to clarify their recommendations twice before the facility complied.

Staff also failed to use enhanced barrier precautions for residents with urinary catheters and open wounds. Nurses provided wound care without wearing gowns, and nursing assistants repositioned residents with catheters without proper protective equipment.

One resident's urinary catheter was found lying on the floor without a cover on multiple occasions. Another time, the catheter was positioned at the same level as the bladder, preventing proper drainage and increasing infection risk.

The facility removed the immediate jeopardy designation on July 10 after providing cigarette disposal receptacles, completing smoking assessments for all smoking residents, and educating staff on safe disposal procedures. However, the underlying care failures affecting nutrition, pain management, respiratory care, and infection control remained unresolved at the time of the inspection report.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Colfax Health and Rehabilitation of Cascadia from 2024-07-22 including all violations, facility responses, and corrective action plans.

Additional Resources

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