Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colfax Nursing And Rehab, Llc during CMS and state inspections, most recent first.
Failure to follow infection control practices involved a resident with quadriplegia, multiple pressure ulcers, and an open foot lesion who had an EBP sign posted above the bed, yet a CNA provided incontinent care without wearing the required gown. Housekeeping staff also used disinfectants for bathroom cleaning without following the labeled 10-minute dwell time, and the Housekeeping/Maintenance Supervisor was unaware of the proper contact time for the products.
Failure to maintain an effective pest control program was cited after multiple flies were observed in resident rooms, hallways, the dining room, and the kitchen. A resident with intact cognition reported a fly problem, another resident was seen with multiple flies on her while in bed, and residents were observed swatting flies during meals while flies landed near food and on a beverage in the kitchen. The DON and Administrator acknowledged the fly issue, and the pest control contractor stated monthly service included fly control and that the facility had been told to change the bulbs in the fly lights.
Failure to Document Clinical Rationale for Denied GDRs: The facility did not ensure the provider documented a handwritten, valid clinical rationale when declining pharmacy-recommended GDRs for multiple residents receiving psychotropic medications. Residents with diagnoses including bipolar disorder, dementia, schizoaffective disorder, depression, and anxiety were prescribed antipsychotic, antidepressant, antianxiety, and mood-stabilizing medications, but the NP only marked “NO” or “No” on the consultant reports without documenting why dose reduction was contraindicated or whether the minimal effective dose was being used.
Daily nurse staffing data were not completed or posted appropriately. Observations found no staffing display at the entrance or throughout the facility, and S7 Corporate stated the prior ADON had handled the task but was no longer employed. S7 Corporate confirmed the form was not posted, could not verify it had been completed since the ADON left, and stated the Administrator and/or DON were responsible for overseeing the requirement but did not.
Failure to provide water with meals. Staff did not serve water to 32 residents during lunch in the dining room, and only tea was observed on meal trays. A resident stated water is never served unless requested, while the DON and Administrator confirmed that water is only provided if a resident asks for it.
Kitchen Food Safety Deficiency: Staff were observed preparing food with contaminated gloves and without beard restraints. A dishwasher and a staff member preparing puree meals both had beards uncovered, and the food-prep staff member handled a garbage can and then used the same gloves to debone cooked chicken. The dietary manager confirmed the beard restraints were not available and acknowledged the contaminated glove use.
A resident with bipolar disorder, schizophrenia, unspecified dementia, catatonic disorder, autonomic neuropathy, and extrapyramidal movement disorder had a physician order for Full Code status, but the care plan did not include code status information. The Corporate RN confirmed the code status was not care planned even though it should have been.
A resident with COPD, heart failure, and severe cognitive impairment was receiving oxygen therapy without current physician orders. Staff and the resident reported he used oxygen daily, including during naps, after smoking, and at night, and he was observed asleep with oxygen in progress at 2 L via nasal cannula. The DON confirmed the resident had been using oxygen since returning from the hospital, but no current oxygen orders were in the chart.
Inadequate Supervision During Smoking: A resident with hemiplegia, Alzheimer’s disease, CKD, and poor vision/blindness required supervision while smoking per the smoking assessment and care plan. Surveyors observed burn holes in the wheelchair cushion and ashes on the resident’s pant legs, and staff reported the resident needed her wheelchair positioned close to the ashtray because she would drop ashes on herself; the Administrator believed the cushion damage appeared to be from cigarette burns.
Improper Storage of Resident Oxygen Equipment: A resident with COPD, HF, and severe cognitive impairment used oxygen daily and at night, with nurses assisting to apply and remove it as needed. Surveyors observed the oxygen tubing and nasal cannula draped over the concentrator and later placed on the floor, with no storage bag present. The DON confirmed staff knew oxygen equipment should be stored in a Ziploc bag when not in use, but the resident’s equipment was not stored appropriately.
Narcotic reconciliation was inaccurate for one resident’s meds on a medication cart. An LPN gave a PRN benzo but failed to document it on the narcotic log, and also mistakenly documented an anticonvulsant as given when it had not been administered. The DON confirmed the count and documentation errors during the review.
Residents Not Served Together at Dining Table: During mealtime, four residents were seated together at one dining table, but only one resident received a meal tray while staff served other tables first. The remaining three residents at that table were served about 15 minutes later. The Dietary Manager acknowledged that residents seated at the same table should have been served together, but they were not.
Call Light Not Accessible to Resident with Severe Cognitive Impairment: A resident with COPD, CHF, dementia, epilepsy, and schizophrenia, and a BIMS score of 3, was repeatedly observed in bed with the call light on the floor and not within reach. The resident required substantial to maximal assistance with toileting, bathing, and personal hygiene, had a history of falls, and the care plan directed staff to keep the call bed in reach and encourage use of the call bell. An LPN confirmed the call light was not accessible and should have been.
Fifteen resident rooms were found to have hot water temperatures exceeding 120°F, with some readings as high as 140°F. The maintenance supervisor was measuring water temperatures incorrectly, leading to inaccurate logs and unrecognized hazards. No residents or staff reported injuries or complaints, but the facility failed to ensure a safe environment by not properly monitoring and controlling water temperatures.
Residents were restricted to accessing the outdoor patio only during scheduled smoking breaks, despite requests to go outside at other times for fresh air or relaxation. Multiple residents, including those with intact cognition, reported being denied access outside of these times, and staff confirmed that supervision was required and rarely available. This practice was inconsistent with the facility's stated policy on resident rights to dignity and self-determination.
A strong urine odor was observed throughout the facility, with multiple residents and staff confirming persistent unpleasant smells and poor cleanliness. Housekeeping staff noted limited coverage after certain hours, and an LPN reported that soiled diapers were left in room trash cans overnight by agency staff. These actions and inactions resulted in the facility not maintaining a clean, comfortable, and homelike environment as required by policy.
A resident with cognitive impairments physically abused another resident due to agitation over a perceived odor. The incident resulted in a cut on the victim's lip. Staff failed to report the aggressor's behavior to nursing staff, violating the facility's abuse prevention policy.
A resident with moderate cognitive impairment was sexually abused by a roommate with intact cognition and a history of inappropriate behavior. The incident was reported two days later, and the facility moved the victim to a different hall. The facility's abuse prevention policy was not effectively implemented, leading to this deficiency.
A facility failed to implement a care plan for a resident with Major Depressive Disorder and did not document food intake or notify the physician and family of another resident's significant weight loss. The DON confirmed these deficiencies, highlighting a lack of person-centered care planning and communication.
The facility did not adhere to the menu for a lunch meal, failing to serve the specified 2 ounces of roasted turkey gravy with the meal. Observations and interviews with dietary staff confirmed the absence of gravy on the serving line, resulting in a failure to meet the nutritional needs of residents.
The facility failed to prepare pureed foods according to standardized recipes, affecting eight residents on pureed diets. A dietary staff member did not measure ingredients or use the recipe, and the dietary manager confirmed the recipes were not followed due to being misplaced. A registered dietitian highlighted the necessity of following recipes to ensure adequate caloric intake.
The facility failed to maintain professional standards for food service safety, with unmonitored refrigerator and freezer temperatures, undated food items, and unsanitary kitchen equipment. Observations included unclean microwaves and ice machines, and a lack of sanitizer checks in the 3-compartment sink, confirmed by dietary staff.
The facility failed to serve residents sitting at the same dining table simultaneously, leading to delays of 9 and 19 minutes for some residents. This practice was confirmed by the DON, who acknowledged that residents should have been served together.
The facility failed to maintain a clean and homelike environment, with observations revealing unsanitary conditions in resident rooms and common areas. Residents reported infrequent cleaning due to understaffing, and maintenance issues such as water-stained ceiling tiles and improperly fitted air conditioning units were noted. Shower rooms were found with soap scum and urine stains, and the DON confirmed inadequate cleaning practices.
The facility failed to provide necessary ADL assistance to several residents, including bathing, nail care, and shaving. Observations revealed residents with unmet hygiene needs, such as long, dirty fingernails and infrequent bathing. Interviews confirmed the lack of documentation and assistance, despite the facility's policy requiring such care.
The facility failed to serve meals at regular times as per residents' needs and preferences, with breakfast and lunch consistently delayed. Observations and interviews revealed that meals were served late due to staffing shortages in the kitchen, affecting all residents in the dining room. A resident reported receiving dinner at 6:00 p.m. instead of 4:00 p.m., and lunch around 2:00 p.m. instead of 11:30 a.m. The Dietary Manager acknowledged the lack of a staffing schedule and uncertainty about adequate staffing levels.
The facility failed to maintain an effective pest control program, leading to a significant fly infestation affecting residents and the dining area. Despite having a pest control service contract, there were lapses in addressing reported fly issues, and recommended measures were not implemented.
The facility failed to inform two residents of potential charges for services not covered by Medicare, as required by policy. The ABN notices sent to the residents' representatives lacked estimated costs, which was confirmed by facility staff responsible for issuing these notices.
A facility failed to complete a timely quarterly MDS assessment for a resident with multiple diagnoses, including dementia and chronic kidney disease. The last assessment was completed several months ago, and the corporate nurse confirmed the delay, citing the absence of an MDS nurse.
The facility failed to follow physician orders for a dermatology referral for a resident with facial cysts and did not report abnormal lab results or recollect a urine sample for another resident with a history of UTIs. The responsible staff did not notify the provider or perform necessary follow-ups, leading to lapses in care.
A resident with a history of dementia and coronary artery disease was observed using oxygen therapy without a physician's order, contrary to the facility's policy. The resident's care plan included oxygen administration, but no order was found in the medical records. An LPN confirmed the need for oxygen but acknowledged the lack of an order.
The facility did not include the Medical Director in a required QAA committee meeting. The sign-in sheet for the meeting showed the Medical Director was absent, and the Corporate Nurse confirmed this, stating that the Medical Director reviews the meeting information later.
The facility failed to secure handrails in Hall Y, as observed between rooms L and M. The Maintenance Supervisor confirmed the handrails were not properly affixed, potentially affecting 24 residents.
Failure to Follow EBP and Disinfectant Dwell-Time Requirements
Penalty
Summary
The facility failed to implement and maintain infection control practices to help prevent and control the spread of infectious communicable diseases. One deficiency involved Resident #4, who had diagnoses including chronic multifocal osteomyelitis of the right femur, a stage 4 pressure ulcer of the right hip, a stage 3 pressure ulcer of the sacral region, and quadriplegia. The resident’s quarterly MDS showed a BIMS score of 15, indicating intact cognition, and the care plan stated the resident was bedbound, totally dependent on staff for care, and had a chronic stage 4 pressure ulcer, an open lesion to the right lateral foot, a stage 3 pressure ulcer to the sacrum, and MASD to both feet. Observation showed an EBP sign posted above the resident’s bed stating that gown and gloves must be worn for all direct patient care. However, a CNA stated she provided incontinent care throughout her shift and was unaware the resident required EBP during incontinent care; she later acknowledged she had not worn a disposable gown when providing that care, although she should have. The facility also failed to follow chemical manufacturer dwell-time guidelines for sanitation. Housekeeping staff stated that Room Sense 200 Lemon Disinfectant cleanser was used for bathroom cleaning and wiped up after 2 to 3 minutes of contact time, even though the bottle indicated a 10-minute dwell time. Another housekeeper stated Room Sense 200 Lemon Disinfectant Cleanser and hdqC2 Neutral Disinfectant were used for bathroom cleaning and was unaware the chemicals had dwell times. The Maintenance Supervisor, who also served as the Housekeeping Supervisor and provided training to housekeeping staff, reviewed the bottles and confirmed he was unaware of the proper 10-minute dwell time for the chemicals.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, with multiple flies observed in resident rooms, hallways, the dining room, and the kitchen. On 08/25/2025 and 08/26/2025, surveyors observed flies around Resident #1 while he was in bed, multiple flies in Hall Y, and flies in the dining room during meal service. In the dining room, a resident was observed swatting at flies while eating, another resident yelled that he could not eat because of the flies, and residents were seen using fly swatters. In the kitchen, flies were observed above the table where puree meals were being prepared and around the steam table, including landing on the rim of an uncovered glass of tea that was about to be served. Resident #29, who had a BIMS score of 15 indicating intact cognition, reported multiple flies in his bedroom and stated there was a fly problem in the facility. Resident #10 was observed with multiple flies on her while lying in bed on several occasions, and she stated the flies in her room were very bad and pointed to her roommate, saying the roommate ate in bed and threw items on the floor. The facility’s pest control policy stated the building should be kept free of insects and rodents, and the pest control contractor reported monthly basic service included fly control and that the facility had been told to change the bulbs in the fly lights. The Administrator and DON acknowledged the fly problem and confirmed pest control could be called as needed, while invoices showed monthly services in June, July, and August 2025, with the last visit on 08/04/2025.
Failure to Document Clinical Rationale for Denied GDRs
Penalty
Summary
The facility failed to ensure the physician documented a clinical rationale when denying gradual dose reductions (GDRs) for psychoactive medications for multiple residents reviewed for unnecessary medications. The report states that the pharmacy consultant requested GDRs for residents receiving antipsychotic, antidepressant, antianxiety, and mood-stabilizing medications, but the nurse practitioner documented only “NO” or “No” without a handwritten, valid clinical rationale explaining why dose reduction was not appropriate or why it would be clinically contraindicated. Resident #5 had diagnoses including cerebral infarction, bipolar disorder, and unspecified dementia without behavioral, psychotic, mood, or anxiety disturbance. The resident’s record showed a BIMS score of 10 and active orders for brexpiprazole, sertraline 150 mg daily, and divalproex 750 mg twice daily. The pharmaceutical consultant recommended GDRs for brexpiprazole, divalproex, and both sertraline orders, but the signed and undated consultant report contained only a “NO” response from S11 NP and no handwritten clinical rationale. Resident #38 had diagnoses including Alzheimer’s disease, bipolar disorder, major depressive disorder, and anxiety disorder, and the MDS indicated the resident was rarely understood. The resident received lorazepam 1 mg four times daily, divalproex sprinkles 125 mg two capsules twice daily, and quetiapine 25 mg twice daily. The consultant requested GDRs for these medications, but S11 NP again documented “NO” without indicating whether the resident was receiving the minimal effective dose and without a handwritten clinical rationale. Resident #7 had diagnoses including unspecified dementia with anxiety and schizoaffective disorder, with a BIMS score of 3 indicating severe cognitive impairment. The resident received haloperidol decanoate injections and sertraline 100 mg daily. The consultant requested GDRs for both medications, but S11 NP did not document whether a dose reduction was appropriate or whether the resident was receiving the minimal effective dose, and no handwritten clinical rationale was provided. Resident #12 had diagnoses including psychotic disturbance, mood disturbance, anxiety, schizoaffective disorder depressive type, and depression, with a BIMS score of 12. The resident received sertraline 200 mg daily, buspirone 5 mg twice daily, haloperidol 5 mg daily, and haloperidol decanoate monthly. The consultant requested GDRs for these medications, but S11 NP documented “No,” signed her name without dating it, and did not provide a handwritten clinical rationale. The DON confirmed that the 07/2025 GDRs were not completed by the medical provider but should have been.
Daily Nurse Staffing Data Not Posted
Penalty
Summary
The facility failed to ensure that daily nurse staffing data were completed and posted appropriately. Observation at the facility entrance on 08/25/2025 at 2:06 p.m. and again throughout the facility on 08/26/2025 at 10:50 a.m. found no display of the daily nurse staffing data. During interview, S7 Corporate stated that the previous ADON had been responsible for completing the staffing data form, but since that employee was no longer employed, he was unaware of who was currently responsible for the task. S7 Corporate confirmed at 10:55 a.m. that the daily nurse staffing data form was not completed and displayed appropriately, stated, "It's not posted, so it is not done," and was unable to verify or provide evidence that the daily nurse staffing data had been completed since the previous ADON's last day of employment on 06/06/2025. S7 Corporate also confirmed that the Administrator and/or DON were responsible for overseeing that the daily nurse staffing data was completed and posted, but did not.
Failure to Provide Water With Meals
Penalty
Summary
The facility failed to provide drinks, including water, consistent with resident needs and preferences and sufficient to maintain hydration. During lunchtime in the dining room, staff did not provide water to 32 residents with their meal, and only tea was observed on the lunch tray. Resident #1, who eats most meals in the dining room, stated that water is never served with the trays unless it is asked for. A resident in the dining area was heard hollering out for water instead of the tea that was served. The DON stated that residents are only served water with meals if they ask for it, and the Administrator stated that the facility does not serve water on meal trays unless the resident specifically asks for it.
Kitchen Food Handling and Beard Restraint Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. During observation, kitchen staff were seen handling food with contaminated gloves and not wearing beard restraints while preparing food. The facility’s policy stated that employees must wash hands after handling soiled equipment or utensils and during food preparation as often as necessary to prevent contamination, and that hair nets, caps, and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. On 08/25/2025 at 11:10 a.m., a dishwasher was observed rolling silverware in napkins while having a beard that was not covered with a beard restraint. At 11:18 a.m., a staff member preparing puree meals was also observed with a beard not covered by a beard restraint. That same staff member donned gloves, moved a garbage can by the handle to the puree table area, and then used the same gloves to pick up cooked chicken thighs and begin deboning them for the blender. In interview, the staff member confirmed he had moved the garbage can and then handled the chicken with the same gloves. The dietary manager later confirmed both staff members were not wearing beard restraints because the facility did not have any on hand, and acknowledged the staff member had touched the garbage can and then handled the chicken with contaminated gloves.
Code Status Not Included in Care Plan
Penalty
Summary
The facility failed to ensure a physician's order was implemented as required in the person-centered plan of care for Resident #64. The resident was admitted on 05/01/2025 with diagnoses including Bipolar Disorder, Schizophrenia, Unspecified Dementia, Catatonic Disorder due to known Physiological Condition, Idiopathic Peripheral Autonomic Neuropathy, and Extrapyramidal Movement Disorder. The resident's quarterly MDS with an ARD of 07/30/2025 showed a BIMS score of 10, indicating moderately intact cognition. Review of the physician orders showed Full Code status ordered on 05/01/2025, but the care plan reviewed on 10/31/2025 did not include any code status information. During an interview on 08/26/2025 at 10:38 a.m., the Corporate RN confirmed that the resident did not have code status care planned, but should have been.
Missing Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that all care and services were provided according to accepted professional standards of clinical practice when it did not obtain proper physician orders for a resident’s oxygen therapy. The facility policy on oxygen administration stated that there must be a physician’s order before the procedure is provided. Resident #30 was admitted with diagnoses including chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, heart failure, and essential hypertension, and his quarterly MDS showed severe cognitive impairment with a BIMS score of 4. Review of the resident’s current and discontinued physician orders showed no orders for oxygen therapy, yet the medical record and staff interviews documented that he was receiving oxygen. A nursing progress note documented oxygen at 2 liters via nasal cannula, the resident stated he used oxygen every night, and staff reported he used oxygen daily, including during naps, after smoking, and at night. The resident was observed asleep in bed with oxygen in progress via concentrator at 2 liters via nasal cannula, and the DON confirmed the resident had been using oxygen since returning from the hospital but had no current physician orders for oxygen therapy.
Inadequate Supervision During Smoking
Penalty
Summary
The facility failed to ensure a resident received adequate supervision to prevent accidents while smoking. The facility’s undated Smoking Policy stated that, for safety reasons, it was intended to increase safety and decrease fire and burn risk, and that the facility provides appropriate ashtrays and supervision, with protective items such as burn aprons, extenders, or smoking gloves used if necessary. Resident #34 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, squamous cell carcinoma of the skin, chronic pain syndrome, Alzheimer’s disease with early onset, chronic kidney disease, acute chronic diastolic disease stage 3, major depressive disorder, and recurrent severe without psychotic features. The resident’s smoking assessment stated that supervision would be required for all residents during designated smoking times and identified poor vision or blindness as present. The care plan also stated that the resident required supervision while smoking. During observation, the resident was seen in a wheelchair with five burn holes on the raised centered ridge of the pommel cushion, and later the cushion still had burn holes while ashes were observed on the resident’s pant legs near the center ridge of the cushion. A CNA stated that if staff did not pull the resident’s wheelchair under the table close to the ashtray, she would drop ashes on herself. The Administrator stated the holes in the wheelchair cushion appeared to be from cigarette burns, and the Corporate RN stated she was responsible for the smoking assessments but was not aware of anyone notifying her or the DON that the resident had issues putting out cigarettes or dropping ashes on herself.
Improper Storage of Resident Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for a resident with COPD, hypertensive heart disease with heart failure, heart failure, and essential hypertension. The resident’s quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment. The medical record did not contain documentation in the current plan of care regarding refusal of oxygen storage or equipment, and the facility could not provide an oxygen storage policy. Surveyors observed the resident’s oxygen concentrator with the oxygen tubing draped over the concentrator and no storage bag present. On another observation, the oxygen tubing and nasal cannula were placed directly on the floor, again with no storage bag observed. The resident stated he used oxygen therapies every night and that the nurse helped him apply it. Staff interviews confirmed the resident used oxygen daily or PRN for shortness of breath, including while in bed, after smoking, and during naps, and that nurses applied and removed the oxygen when needed. The DON confirmed staff were aware that resident oxygen equipment such as tubing and nasal cannula should be stored in a Ziploc bag when not in use, and confirmed the resident’s oxygen tubing and nasal cannula were not stored appropriately.
Narcotic Reconciliation Errors on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing, and administration of medications for one resident on Hall X during narcotic reconciliation review. The facility’s controlled substances policy required inventory monitoring and reconciliation using access and usage records, MARs, declining inventory records, and destruction, waste, and return-to-pharmacy records. For Resident #80, physician orders included Lorazepam 2 mg by mouth every 6 hours as needed for anxiety related to generalized anxiety disorder and Lacosamide 100 mg by mouth twice daily related to other seizures. During observation of the Hall X medication cart, Resident #80’s Lorazepam blister pack had 18 tablets remaining, while the narcotic log showed 19 tablets remaining and listed the last dose as given on 08/19/2025 at 11:44 p.m. Resident #80’s Lacosamide blister pack had 50 tablets remaining, while the narcotic log showed 49 tablets remaining and listed a dose as given on 08/27/2025 at 8:30 a.m. An LPN confirmed she gave the PRN Lorazepam at 8:30 a.m. but did not document it on the narcotic log, and also confirmed she accidentally documented Lacosamide as given when it had not been administered. The DON confirmed the Lacosamide count was 50 tablets and that the LPN marked it as given without giving it, and confirmed the Lorazepam narcotic log had not been updated as it should have been.
Residents Not Served Together at Dining Table
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime by not ensuring that residents seated together at the same dining room table were served their meals at the same time. During observation, four residents were seated together at one table, but only one resident at that table was initially served a meal tray while staff delivered trays to other residents seated at different tables. The remaining three residents at the same table were not served until about 15 minutes later. The facility policy on dignity stated that residents should be provided with a dignified dining experience, and the Dietary Manager acknowledged that residents seated at the same table should have been served together but were not.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not ensured when Resident #32’s call light was repeatedly found inaccessible. Resident #32 was admitted on 12/02/2021 and had diagnoses including COPD, CHF, unspecified dementia, epilepsy, and schizophrenia. The resident’s MDS dated 08/13/2025 showed a BIMS score of 3, indicating severe cognitive impairment, and the resident required substantial to maximal assistance with toileting, bathing, and personal hygiene, as well as partial to moderate assistance with transfers. The care plan identified a history of falls, including 7 documented falls in August 2025, and included interventions to encourage the resident to call for assistance and keep the call bed in reach when in the room. During multiple observations, the resident was seen lying in bed awake and alert, awake, sleeping, and sitting up in bed, while the call light was observed on the floor under a piece of furniture or on the floor and not accessible. On 08/27/2025, an LPN confirmed the call light was on the floor and stated it was not accessible to the resident and should have been. The facility policy stated each resident is to be provided a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
Failure to Maintain Safe Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident environments were free from accident hazards by not maintaining hot water temperatures at or below 120 degrees Fahrenheit in 15 out of 28 resident rooms. Observations revealed that water temperatures in these rooms ranged from 122.0 to 140.0 degrees Fahrenheit, exceeding the facility's policy and the recommended safety threshold to prevent scalding. The deficiency was identified during a survey when a maintenance supervisor was observed measuring water temperatures incorrectly, using the middle of the thermometer instead of the tip, which led to inaccurate documentation of water temperatures in the facility's logs. The logs for several months did not reflect any temperatures above 120 degrees Fahrenheit, despite actual measurements showing otherwise. Interviews with the maintenance supervisor, DON, and administrator confirmed that the method used for measuring water temperatures was incorrect and that the temperatures in the affected rooms were indeed above the safe limit. However, there were no reported incidents, injuries, or complaints from residents or staff regarding excessively hot water. The deficiency was based on the failure to accurately monitor and control water temperatures as required by facility policy, resulting in a hazardous environment for residents.
Failure to Honor Resident Rights to Outdoor Access and Dignity
Penalty
Summary
The facility failed to honor residents' rights to dignity and self-determination by restricting access to the outdoor patio area to only three scheduled times per day, which coincided with smoking breaks. Multiple residents, including those with both moderate cognitive impairment and intact cognition, reported that they were not allowed to go outside except during these designated times. Residents stated they had requested to go outside for fresh air or relaxation at other times but were told by staff that it was not permitted or that staff would get in trouble for allowing it. Staff interviews confirmed that residents were only allowed outside during smoking times unless a staff member was available, which rarely occurred due to workload. The facility's policy stated that residents have the right to independent personal decisions and to be treated with respect and dignity, but this was not reflected in practice. Resident council minutes also documented that residents had expressed a desire for more frequent access to the patio for non-smoking purposes. Despite administrative claims that nothing was preventing residents from going outside if staff were available, both staff and residents consistently reported that access was limited and requests outside of scheduled times were routinely denied. The restriction applied regardless of residents' cognitive status, and some residents described feeling confined as a result. The deficiency was identified through interviews, record reviews, and review of facility policy and resident council minutes.
Failure to Maintain Sanitary and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable homelike environment for all residents by not ensuring the facility was free of odor, specifically a strong urine smell. Upon entrance, a strong urine odor was noted throughout the facility, and this was corroborated by multiple observations and interviews. Resident council minutes documented complaints about unpleasant hallway odors, with staff responses attributing the smell to residents who change themselves and leave soiled items in their rooms. Observations included a persistent strong odor in specific halls and resident rooms, with one room also having a sticky floor. Residents interviewed described poor cleanliness, infrequent mopping, and dissatisfaction with the facility's sanitation. Housekeeping staff confirmed the presence of a strong urine odor and noted that there is no housekeeping coverage after 3:00 p.m., which may contribute to lingering odors from items like linen barrels not being sent to laundry. An LPN also reported a strong urine odor in the morning and indicated that agency staff had left soiled diapers in room trash cans overnight. These findings collectively demonstrate a failure to provide a clean, odor-free, and comfortable environment as required by facility policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved Resident #4, who was physically abused by Resident #5. Resident #5 became agitated due to a perceived odor in the room and began stripping the linen off Resident #4's bed. Despite Resident #4's protests, the situation escalated into a physical altercation in the hallway, where Resident #5 hit Resident #4, resulting in a small cut on Resident #4's lip. Resident #4 has a medical history that includes paraplegia, schizophrenia, schizoaffective disorder, bipolar disorder, and a history of traumatic brain injury. The resident requires assistance with daily activities and is always incontinent of bladder and bowel. Resident #5, who has diagnoses including epilepsy, dementia, schizoaffective disorder, and profound intellectual disabilities, also requires supervision for personal care activities. Both residents have moderate cognitive impairments as indicated by their BIMS scores. The facility's staff, specifically S3 CNA and S4 CNA, failed to report Resident #5's aggressive behavior and increased agitation to the nursing staff. Despite witnessing the initial signs of agitation and the subsequent altercation, the CNAs did not take appropriate action to prevent the escalation. The facility's policy on abuse prevention was not effectively implemented, as the staff did not follow the protocol for reporting and responding to aggressive behaviors, leading to the incident of resident-to-resident abuse.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident #33, who has moderate cognitive impairment, reported an incident where his roommate, Resident #75, attempted to pull down his pants and made inappropriate sexual comments. This incident occurred while Resident #33 was asleep, and he reported it to the Day Program staff two days later. Resident #75, who has intact cognition and a history of socially inappropriate behavior due to Schizoaffective Disorder, admitted to touching Resident #33 but claimed it was a joke. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the occurrence of this incident. The report indicates that Resident #33 was moved to a different hall after the facility was notified, but the initial failure to prevent the abuse constitutes a deficiency. The administrator confirmed the incident and noted that Resident #75 had not shown inappropriate sexual behavior since the event.
Failure to Implement Care Plans for Depression and Weight Loss
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident #59, who was diagnosed with Major Depressive Disorder among other conditions. Despite receiving antidepressant and antianxiety medications, the resident's care plan did not address their depression and anxiety. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging that the resident should have been care planned for these conditions. Additionally, the facility did not adequately monitor and document the food intake of Resident #26, who experienced significant weight loss. The resident's care plan included interventions for altered nutrition due to various health issues, but staff failed to record food intake and notify the resident's physician and family of the weight loss since September 2023. The DON confirmed the lack of documentation and communication regarding the resident's nutritional status and weight changes.
Failure to Serve Menu-Specified Gravy
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not following the established menu for a lunch meal on 06/02/2024. The menu specified that 2 ounces of roasted turkey gravy should accompany the oven-roasted turkey breast, au gratin potatoes, and green peas. However, observations during the food serving process revealed that the roasted turkey gravy was not served to the residents. This was confirmed through interviews with the dietary staff, including S6 Dietary Cook and S5 Dietary Manager, who acknowledged that the gravy was not present on the serving line and was not included on the trays prepared for the residents.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to the approved recipe, which is necessary to conserve nutritional value for eight residents on pureed diets. During an interview, a dietary staff member admitted to not measuring the amount of turkey added to a pureed dish and not using the standardized recipe. The dietary manager confirmed that the recipes for pureed meals were not followed because they could not be located, although they should have been. Additionally, a registered dietitian emphasized the importance of following recipes to ensure residents receive adequate caloric intake.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and sanitation. Observations revealed that the refrigerator and freezer temperature logs were not checked or documented from May 31 to June 2, 2024. Additionally, bags of breadsticks in the walk-in freezer were found open and undated, which was confirmed by a dietary staff member. The 3-compartment sink, essential for maintaining sanitation, was found with water in all compartments and cooking utensils on the sanitizer side shelf, with the staff admitting to not checking the sanitizer level due to time constraints. Further observations highlighted cleanliness issues within the kitchen. The microwave was noted to have multiple food particle splatters inside, and the ice machine had a dark brown/black substance on its inner surface, which was dripping onto the ice below. The ice scoop was stored in a holder with a similar dark substance at the bottom. These observations were confirmed by the dietary staff member present, indicating a failure to maintain clean and sanitary kitchen equipment.
Failure to Serve Residents Simultaneously at Mealtime
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime by not ensuring that residents sitting at the same dining room table were served their meals together. On two separate occasions, observations revealed that one resident at a table was served their meal while the other resident at the same table had to wait for a significant amount of time before being served. Specifically, on one occasion, a resident was served 19 minutes after their tablemate, and on another occasion, a resident was served 9 minutes later than their tablemate. This practice was confirmed by the Director of Nursing (DON), who acknowledged that residents sitting together should have been served simultaneously.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by multiple observations of unsanitary conditions in resident rooms and common areas. Observations revealed significant cleanliness issues, including food debris, sticky floors, and strong urine odors in resident rooms and hallways. Interviews with residents and staff confirmed that housekeeping services were insufficient, with reports of rooms not being cleaned regularly due to understaffing. The housekeeping department was noted to be operating with reduced hours and insufficient staff, making it challenging to maintain cleanliness standards. Further observations highlighted maintenance issues in several rooms, including loose, cracked, and water-stained ceiling tiles, improperly fitted air conditioning units, and stained privacy curtains. Residents expressed dissatisfaction with their living conditions, noting the inability to open blinds for natural light and the presence of flies and gnats. Maintenance staff confirmed these findings, indicating a lack of timely repairs and upkeep in the facility. The facility's shower rooms were also found to be in poor condition, with water-stained and loose ceiling tiles, soap scum, and urine stains on shower chairs. The DON confirmed that the whirlpools and shower chairs had not been cleaned or disinfected after use, as required. These observations and interviews collectively demonstrate a failure to provide a safe, clean, and homelike environment for residents, as mandated by the facility's policies and regulations.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform Activities of Daily Living (ADLs) independently, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in five out of seven residents reviewed for ADLs. The facility's policy required appropriate care and services for residents unable to carry out ADLs independently, including hygiene support such as bathing, dressing, grooming, and oral care. However, observations and interviews revealed that residents were not receiving these services as required. Resident #66, who had severe cognitive impairment and required assistance with personal hygiene, was observed with long, jagged, and dirty fingernails. Despite expressing a desire to have his nails cleaned and cut, this was not done. Similarly, Resident #6, who was dependent on staff for bathing, reported only receiving baths once a week instead of the scheduled three times per week. The CNA responsible for Resident #6 confirmed the lack of documentation for bathing and stated that the computer system did not allow her to document when a resident received a bath. Resident #12, who required setup assistance for bathing, also reported only receiving a bath once a week. Resident #87, who required substantial assistance with personal hygiene, expressed frustration over being left in a dirty diaper and only receiving a bath once a week. Additionally, Resident #10, who could not shave himself due to hand issues, was observed with long facial hair and stated that he believed the facility lacked razors. The DON confirmed that the facility had the necessary equipment and that Resident #10 should have been shaved during his bath but was not.
Meal Service Timing Deficiency Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that meals were served at regular times in accordance with residents' needs and preferences, as observed during multiple meal services. The facility's policy stated that meals should be served at scheduled times, with breakfast at 6:30 a.m., lunch at 11:30 a.m., and dinner at 4:30 p.m. However, observations revealed that meals were consistently served late, with breakfast starting at 8:00 a.m. and lunch being served as late as 12:20 p.m. and 1:20 p.m. on different days. Interviews with residents and staff confirmed these delays, with one resident reporting receiving dinner at 6:00 p.m. instead of the scheduled 4:00 p.m., and lunch around 2:00 p.m. instead of 11:30 a.m. The delays in meal service were attributed to staffing shortages in the kitchen, as noted by a dietary staff member who mentioned being short-handed for several weeks. The Dietary Manager, who was recently hired, acknowledged the lack of a staffing schedule for June 2024 and was uncertain if the staffing levels were adequate to serve meals on time. During a Resident Council meeting, residents expressed concerns about receiving meals 1 to 2 hours late, indicating that the issue was widespread and affected multiple residents. This deficiency in meal service timing had the potential to impact all residents who were served meals in the dining room.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies throughout the building, particularly affecting residents in Hall X and the dining area. Observations revealed multiple flies in several residents' rooms, with residents expressing ongoing issues with flies and dissatisfaction with the facility's efforts to address the problem. The presence of flies was also noted in the dining area, where residents were observed swatting flies away while eating, further indicating the extent of the issue. Interviews with staff and review of the facility's pest control logs revealed that although the facility had a pest control service contract, there were lapses in addressing reported fly sightings. The pest control service was contracted to perform monthly services and additional treatments as needed, but the logs showed no follow-up for reported fly issues in October and November 2023, and no entries for June 2024. The pest control worker confirmed monthly treatments and had recommended additional measures like air curtains and fly lights, which the facility had not implemented. The administrator acknowledged the problem and the lack of action on the recommendations.
Failure to Inform Residents of Potential Charges
Penalty
Summary
The facility failed to inform residents of the charges for services they may be responsible for paying, specifically for two residents out of a sample of three. The facility's policy requires that if the director of admissions or benefits coordinator believes that Medicare will not cover certain skilled services, the resident or their representative must be notified in writing about the potential non-coverage and their financial liability. However, the review of the Advanced Beneficiary Notices (ABN) for two residents revealed that the estimated cost sections were left blank, failing to inform the residents or their representatives of the potential charges. Interviews with facility staff confirmed the oversight. S10 Clerical, responsible for sending the ABN notices, acknowledged that the estimated cost sections were not completed for the two residents. S11 Office Manager, the supervisor of S10 Clerical, also confirmed the omission, stating that the estimated costs should have been included in the notices. This failure to provide complete information on the ABN notices led to the deficiency identified by the surveyors.
Failure to Complete Timely Quarterly Assessment
Penalty
Summary
The facility failed to ensure that a quarterly assessment was completed in a timely manner for one resident. The resident, who was admitted with diagnoses including hyperlipidemia, seizures, schizoaffective disorder, dementia, and chronic kidney disease, had their last quarterly MDS assessment completed on January 24, 2024. Since then, no further quarterly assessments were accepted. During an interview, the corporate nurse acknowledged the absence of an MDS nurse at the facility and confirmed that the resident's quarterly MDS assessment was not submitted on time.
Failure to Follow Physician Orders and Report Abnormal Lab Results
Penalty
Summary
The facility failed to follow physician's orders for a dermatology referral for Resident #30, who had been trying to get three cysts removed from his face for about six months. Despite the resident's intact cognition and repeated complaints to the Nurse Practitioner and a doctor, no appointment was made. The Nurse Practitioner had documented the need for a dermatology evaluation in a progress note, but the clerk responsible for scheduling the appointment was not informed, resulting in no referral being made. For Resident #23, the facility did not report abnormal lab results to the provider or recollect a urine sample as recommended. The resident, who had a history of urinary tract infections and was dependent on staff for personal care, had abnormal urine analysis results indicating probable contamination. The staff failed to notify the provider of these results and did not perform a recollection of the urine sample, as recommended by the lab report. The Director of Nursing confirmed that the staff did not sign off on the lab report or notify the medical provider, which was a deviation from the expected protocol. Interviews with the Director of Nursing and the Nurse Practitioner revealed that the staff did not follow the proper procedures for handling abnormal lab results. The Nurse Practitioner stated that she would not have treated the resident with antibiotics due to chronic colonization and lack of symptoms, but expected a recollection of the urine sample. The failure to notify the provider and recollect the sample was attributed to the staff not reviewing the lab results, leading to a lapse in care for Resident #23.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident, identified as Resident #87, who was receiving oxygen therapy without a physician's order. The facility's policy on oxygen administration requires a physician's order for the procedure, but a review of Resident #87's medical records revealed no such order was present. Despite this, observations on two separate occasions showed Resident #87 using oxygen at 2L/min via nasal cannula, and the resident confirmed frequent use of oxygen, particularly while sleeping. Resident #87 had a history of Unspecified Dementia, Major Depressive Disorder, Alzheimer's Disease, and Coronary Artery Disease, with a moderate cognitive impairment indicated by a BIMS score of 10. The resident's care plan included administering oxygen as ordered and monitoring oxygen saturation, yet no order for oxygen administration was found in the resident's June 2024 orders. An LPN confirmed the resident required oxygen but acknowledged the absence of a physician's order for the therapy.
Medical Director Absence in QAA Meeting
Penalty
Summary
The facility failed to include the Medical Director or his designee in the Quality Assessment and Assurance (QAA) committee's quarterly meeting, as required by regulations. The facility had a total census of 84 residents at the time. A review of the sign-in sheet for the QAA meeting held on March 29, 2024, showed that the Medical Director was not present. During an interview on June 4, 2024, the Corporate Nurse confirmed that the Medical Director did not sign the attendance sheet for the meeting. The Corporate Nurse stated that when the Medical Director does not attend a meeting, he reviews the information at a later time.
Loose Handrails in Hallway
Penalty
Summary
The facility failed to ensure that handrails in the hallways were securely affixed to the walls, specifically in Hall Y. During an observation, it was noted that the handrails between rooms L and M on Hall Y were loose. This observation was confirmed by the Maintenance Supervisor, who acknowledged that the handrails were not secured properly to provide safety. This deficiency had the potential to affect 24 residents residing on Hall Y.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 104 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colfax
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Nursing And Rehabilitation Of Pollock | 16.3 mi | ★★★★★ | 9 | 0 |
| Tioga Community Care Center | 17.2 mi | ★★★★★ | 1 | 0 |
| Lexington House | 19.2 mi | ★★★★★ | 3 | 0 |
| The Oaks Care Center | 19.7 mi | ★★★★★ | 7 | 0 |
| Matthews Memorial Health Care Center | 20.3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.