Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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 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.
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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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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 | — | 8 | 0 |
| Tioga Community Care Center | 17.2 mi | — | 1 | 0 |
| Lexington House | 19.2 mi | — | 2 | 0 |
| The Oaks Care Center | 19.7 mi | — | 7 | 0 |
| Matthews Memorial Health Care Center | 20.3 mi | — | 10 | 0 |
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