Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Colonial Acres Of Humboldt during CMS and state inspections, most recent first.
Expired and improperly dated food items were found in the storage room, including condensed milk, Splenda, poppy seeds, graham cracker pie crusts, cake sprinkles, vanilla pudding, cheesecake mix, and ranch dressing mix. Several opened dry goods were marked only with a month and date and no year, and the Dietary Mgr confirmed the expired items and undated packages should be discarded.
Uncovered clean linen carts were observed being pushed down two hallways with clean linens exposed. The facility policy required clean items to be in a covered cart or truck designed for clean laundry only, and the DON confirmed the cart was not covered during linen delivery.
Missing COVID-19 Vaccine Documentation for Staff: The facility failed to document that the COVID-19 vaccine was offered to staff, that education on the vaccine was provided, and that current vaccine status was maintained for 5 of 5 sampled employees. Employee files for multiple MAs and a NA contained no record of vaccine offering, education, or status, and the Infection Preventionist confirmed there was no documentation of these actions despite staff education being provided during orientation and information being posted annually.
Missing Documentation for Annual Nurse Aide Training: The facility failed to document the required 12 hours of annual ongoing training for several nurse aides and MAs. Record reviews showed monthly education calendars with initials in some months, but the records did not include training length, and one employee file had no 2025 calendar at all. HR confirmed there was no documentation that the annual training requirement was completed for these staff members.
The facility failed to provide written transfer notices and bed hold policy information to residents and their representatives for multiple hospital transfers, and an LPN/social services designee confirmed the notices had not been given and the Ombudsman had not been notified. Residents involved had diagnoses including pneumonia, COPD, and rhabdomyolysis, and one resident was transferred for shortness of breath. The facility also lacked a proper discharge summary with a recapitulation of stay for a resident who died and was discharged to a mortuary.
Bathroom vents in rooms 200, 201, 203, 205, 207, 209, 211, and 213 were not functioning and were found with whitish, brown debris. Observations showed the vents did not draw up a 1 ply sheet of toilet paper, and the ADM and Maintenance Director confirmed the vents were not working and had not been checked in a few months.
Failure to document informed consent for psychotropic medications for two residents. One resident with dementia, agitation, anxiety, and depression received Risperidone and Escitalopram without consent documentation, and the DON confirmed no consent was on file. Another resident had orders for Pregabalin, Hydroxyzine, Donepezil, and Fluoxetine, but the record contained no informed consent for psychotropic meds, and the Regional Corporate Nurse confirmed the lack of documentation.
A resident admitted with traumatic subdural hemorrhage, dementia, and depression had physician orders for multiple psychotropic medications, including Bupropion, Divalproex sodium, Quetiapine, and Venlafaxine. The baseline care plan did not include these medications or related interventions, and the DON confirmed the omission. The resident’s BIMS score was 7, indicating severe cognitive impairment.
Staffing information was not posted as required. Surveyors observed no staffing sheet in the hallways, nurses' station, lobby, entrance, or front office areas, and a whiteboard near the nurses' station only listed staff names without hours or census information. An LPN and the ADM confirmed there was no written staffing sheet posted and that the facility used the whiteboard to list scheduled staff.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds, as observed in several cases. Residents with catheters, wounds, urostomies, colostomies, and tube feedings lacked EBP supplies and signage in their rooms. The Director of Nursing was observed assisting residents without the necessary protective equipment, and interviews confirmed the facility's non-compliance with EBP protocols.
A facility failed to document a resident's catheter status on the MDS, despite the resident being admitted with a urinary catheter and having physician's orders for its maintenance. The resident was observed with a catheter bag, but the MDS inaccurately stated no catheter was present. The DON confirmed the documentation error.
A facility failed to include catheter care in a resident's Comprehensive Care Plan, despite the resident having a urinary catheter and physician's orders for its maintenance. The care plan focused on incontinence management but omitted necessary catheter care instructions, which was confirmed as an oversight by the DON.
Expired and Improperly Dated Food Items in Storage
Penalty
Summary
The facility failed to ensure that expired foods were discarded and that open packages of dry food were dated with the month, date, and year. During an observation of the storage room, surveyors found 4 cans of condensed milk with a best used by date of 2/17/26, a bag of opened Splenda with a best used by date of 3/8/26, and 2 plastic containers of poppy seeds with a best used by date of 2/28/26. Surveyors also observed a bag of 4 regular graham cracker pie crusts marked only with 3/27 and no year, a plastic container of cake sprinkles with the cap dated 6/24 or 6/04 and no year, 2 bags of vanilla pudding opened and marked 10/16 with no year, a 4 lb bag of cheesecake mix opened and marked 11/4 with no year, and a 3.2 oz bag of ranch dressing mix dated Nov. 25 with no year. A review of the facility policy titled Food Receiving and Storage stated that dry foods stored in bins are removed from original packaging, labeled, and dated with a used by date. A review of the Food Code 2022 stated that the day or date marked by the food establishment may not exceed a manufacturer's used by date. During interview, the Dietary Manager confirmed being unaware of the year the vanilla pudding, cheesecake mix, and ranch dressing packages had been opened and believed they had been opened this year. The Dietary Manager also confirmed that the graham cracker pie crust had expired and should be thrown away, and that the condensed milk and poppy seeds should be tossed out. The Dietary Manager further confirmed that all opened packages with only a month and date marked should be thrown out.
Uncovered Clean Linen Cart During Delivery
Penalty
Summary
The facility failed to ensure clean linens were delivered in a covered cart to prevent potential cross contamination. On 3/9/26 at 3:00 PM, laundry staff were observed passing clean linens on a cart down the 200 hallway with no cover over the clean linens. On 3/10/26 at 1:30 PM, laundry staff were again observed passing clean linens on a cart down the 300 hallway with no cover over the clean linens. Review of the Environmental Services Standard Operating Policy dated January 13, 2026 stated that clean items must be in a covered cart or truck specifically designed for clean laundry only. The DON confirmed during interview on 3/10/26 at 1:30 PM that the clean linen cart did not have a cover over the clean linens and that the cart should be covered when delivering clean linens down the hallways.
Missing COVID-19 Vaccine Documentation for Staff
Penalty
Summary
The facility failed to maintain staff documentation showing that the COVID-19 vaccine was offered, that education on the COVID-19 vaccine was provided, and that current vaccine status was documented for 5 of 5 sampled employees. Record review of the employee files for Medication Aide D, Medication Aide C, Medication Aide F, Medication Aide B, and Nursing Aide E showed no record of the facility offering the COVID-19 vaccine, no record of education on the COVID-19 vaccine, and no record of each employee’s current vaccine status. Record review of the facility’s Infection Prevention and Control Program, revised in 2018, showed sections on Immunization and Monitoring Employee Health and Safety that encouraged the COVID-19 vaccine, but there was no policy addressing COVID-19 education, offering the COVID-19 vaccine, or documentation of staff vaccine status. The Infection Preventionist stated that staff receive education during orientation and that information is posted annually by the time clock, but also confirmed there was no documentation that the facility had offered the COVID-19 vaccine, provided education on the vaccine, or maintained current vaccine status for employees.
Missing Documentation for Annual Nurse Aide Training
Penalty
Summary
The facility failed to ensure the required 12 hours of annual ongoing training was provided for nurse aides. Record reviews showed that Medication Aide B, Medication Aide C, Medication Aide D, Nurse Aide E, and Medication Aide F did not have documentation demonstrating completion of the required annual training for 2025. The report noted that the deficiency had the potential to affect all residents, and the facility census was 30. Employee file reviews found Monthly Education Calendar 2025 records for Medication Aide B, Medication Aide C, Medication Aide D, and Nurse Aide E, with initials entered in various monthly boxes, but the records did not include the length of the training. Medication Aide F's employee file did not contain a Monthly Education Calendar 2025. An interview with HR confirmed the facility did not have documentation that the required 12 hours of annual ongoing training was completed in 2025 for these staff members.
Failure to Provide Transfer, Bed Hold, Ombudsman, and Death Discharge Documentation
Penalty
Summary
The facility failed to provide written notice of transfer to the hospital and the bed hold policy to the resident and the resident's representative for 3 of 3 sampled residents. Resident 3 was admitted with pneumonia and later transferred to the hospital for a respiratory infection; the census list showed a hospital paid leave, but the medical record contained no notification of transfer or bed hold notice to the resident or representative. Resident 5 was admitted with COPD and had multiple hospital paid leave dates listed on the census, yet the record showed no transfer notice or bed hold notification for those events. Resident 30 was admitted with rhabdomyolysis and had a therapeutic paid leave after being transferred to the hospital for shortness of breath, but again there was no documentation that transfer or bed hold notices were provided to the resident or representative. The facility also failed to notify the Ombudsman of the transfers for Residents 3, 5, and 30. An interview with the Social Services designee confirmed that since November 2025 no written notice of transfer or bed holds had been provided to residents or their representatives, and that the Ombudsman had not been notified of any facility transfers as required. In addition, Resident 31 died and was discharged to a mortuary, but the discharge summary provided was the admission record with handwritten notes about the time of death and items sent with the family and mortician. The document did not include a recapitulation of stay, and the facility's transfer/discharge and post mortem care policies did not address the procedure to follow for a resident death.
Bathroom Ventilation Systems Not Functioning and Contaminated
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were functioning and clean in rooms 200, 201, 203, 205, 207, 209, 211, and 213. Observations on 3/9/2026 and 3/10/2026 showed that the bathroom vents in these rooms did not draw up a 1 ply sheet of toilet paper, indicating the vents were not working. The vents also contained a whitish, brown substance and debris. Interviews with the Administrator and Maintenance Director confirmed that the bathroom vents in these rooms were not working, that debris was present in the vents, and that the ventilation system had not been checked in a few months with no record of the vents being checked.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of the risks, benefits, and alternative treatments for psychotropic medications for 2 of 2 sampled residents, Resident 1 and Resident 8. Resident 8 was admitted with diagnoses including unspecified dementia with agitation, anxiety disorder, and depression, and had a BIMS score of 2 indicating extreme impairment. Resident 8’s orders included Risperidone 0.5 mg at bedtime and Escitalopram 10 mg daily, both of which were administered as ordered in January 2026. The care plan identified psychotropic medication use for flat affect and delusions, with interventions including monitoring for side effects, non-pharmacological interventions, offering snacks and fluids, calling the daughter, and behavior monitoring. The medication records contained no evidence of consent for Risperidone or Escitalopram, and the DON confirmed there was no consent for these medications. Resident 1’s medication orders included Pregabalin, Hydroxyzine, Donepezil, and Fluoxetine. The annual MDS showed a BIMS score of 15, no adverse behaviors or rejection of care, and the care plan included goals and interventions for anxiety, depression, and bipolar disorder. The MAR for March 2026 showed no indication of target behaviors for antidepressant or antianxiety medications, and the admission record and MAR did not show diagnoses supporting Donepezil or Pregabalin. The electronic record did not contain informed consent documentation for psychotropic medications, and when the informed consent document was requested from the Administrator, none was provided. The Regional Corporate Nurse stated there was no documentation of informed consent for Resident 1’s medications.
Baseline Care Plan Missing Psychotropic Medication Information
Penalty
Summary
The facility failed to develop a baseline care plan within the required timeframe for one resident, Resident 33, who was admitted with traumatic subdural hemorrhage with loss of consciousness, dementia, and depression. Physician admission orders dated 3/3/26 included Bupropion, Divalproex sodium, Donepezil, Quetiapine, and Venlafaxine. The admission MDS completed on 3/11/26 showed a BIMS score of 7, indicating severe cognitive impairment. A review of the baseline care plan dated 3/5/2026 showed that it did not include any of Resident 33’s psychotropic medications or interventions related to psychotropic medication use. The facility’s policy stated that a baseline plan of care to meet the resident’s immediate needs shall be developed within 24 hours of admission and include orders and services to be administered by the facility. The DON confirmed in interview on 3/11/26 at 2:00 PM that the baseline care plan did not contain information and interventions for the resident’s psychotropic medications.
Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure staffing information was posted as required. Observations on 03/09/2026 at 1:30 PM, 03/10/2026 at 7:49 AM, and 03/10/2026 at 9:46 AM found no staffing information posted in either hallway, around the nurses' station, in the lobby or entrance areas, or around the front offices. At the 03/10/2026 9:46 AM observation, a whiteboard near the nurses' station had staff names written on it, but there were no hours or census information posted. An interview with an LPN at 9:50 AM confirmed there was no written staffing sheet posted and that the facility wrote the staff scheduled to work on the whiteboard daily. An interview with the Administrator at 9:56 AM confirmed the facility did not have a staffing sheet including census and total hours posted, and that the staff scheduled to work were written on the whiteboard.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the transmission of infections among residents with indwelling devices and wounds. Observations revealed that several residents, including those with urinary catheters, wounds, urostomies, colostomies, and tube feedings, did not have EBP supplies or signage in their rooms. This lack of EBP was noted during various observations, such as when Resident 18 was seen without EBP supplies or signage, despite having open wounds on the buttocks. Similarly, Resident 27, who had a catheter, was observed without EBP measures in place. The Director of Nursing (DON) was observed assisting residents without utilizing the necessary EBP measures. For instance, the DON was seen assisting Resident 18 with personal care without the required protective equipment, and there was no signage indicating the need for EBP. Additionally, Resident 22, who had a urostomy, colostomy, and wound vac, was found without EBP supplies or signage in their room. These observations indicate a systemic failure to adhere to infection control protocols for residents with indwelling devices and wounds. Interviews with the DON confirmed that the facility was not following EBP for residents with indwelling catheters, devices, or wound care. The DON acknowledged the absence of EBP signage and supplies for residents who required them, including Residents 27, 22, 131, 18, and 129. This deficiency highlights a significant lapse in infection prevention and control practices, as the facility did not provide the necessary personal protective equipment or signage to minimize the risk of infection transmission.
Failure to Document Catheter Status on MDS
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident's catheter at the time of admission. Resident 27 was admitted with several diagnoses, including malignant neoplasm of the bladder, kidney stones, hematuria, urinary retention, and obstructive and reflux uropathy. The resident was observed on two separate occasions with a catheter bag hanging from their wheelchair, indicating the presence of an indwelling catheter. However, a review of the resident's MDS documentation revealed that the section regarding bladder and bowel status incorrectly stated that the resident did not have an indwelling catheter. Further record reviews showed that the resident had physician's orders for catheter maintenance, including daily flushing and monthly changes. Despite these orders and the resident's medical history, the MDS failed to document the presence of the catheter. An interview with the Director of Nursing confirmed that the catheter should have been marked on the MDS, acknowledging the oversight in documentation.
Failure to Include Catheter Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop a Comprehensive Care Plan (CCP) for a resident's catheter care, which is necessary to provide effective and person-centered care that meets professional standards of quality. The deficiency was identified for one resident, who was observed on multiple occasions with a catheter bag hanging from their wheelchair. Despite having a physician's order to flush the Foley catheter daily and change it every 30 days, the care plan did not include any instructions or interventions related to catheter care. The resident, who was admitted with a urinary catheter, had a history of bladder cancer, kidney stones, hematuria, urine retention, and obstructive and reflux uropathy. The existing care plan focused on managing the resident's incontinence with interventions such as brief use and checking for wet clothing, but it did not address the specific catheter care needs. The Director of Nursing confirmed that catheter care should have been included in the care plan, indicating a lapse in the facility's care planning process.
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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.
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How nearby facilities compare on the same public inspection record.
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