Colfax Nursing: Call Light Left on Floor - LA
Federal inspectors found the call light under furniture and on the floor during four separate visits to Resident 32's room at Colfax Nursing and Rehab between August 25 and August 27. Each time, the resident was awake and alert but unable to summon help.
The resident has been at the facility since December 2021 with chronic obstructive pulmonary disease, combined heart failure, dementia, epilepsy and schizophrenia. Testing revealed severe cognitive impairment with a score of 3 out of 15 on the cognitive assessment.
Resident 32 requires substantial help with toileting, bathing and personal hygiene. They need moderate assistance for all transfers and have significant mobility limitations and shortness of breath.
The facility's own care plan, created in June 2024, specifically noted the resident's fall risk. Seven falls occurred in August 2025 alone. The care plan's interventions included "encourage the resident to call for assistance" and "keep the call bed in reach when in the room."
It also directed staff to "encourage the resident to use the call bell to call for assistance" due to confusion, dementia, impaired balance, limited mobility and breathing problems.
On August 25 at 9:43 a.m., inspectors observed Resident 32 lying in bed, awake and alert. The call light was on the floor under a piece of furniture, completely out of reach.
The next day at 12:12 p.m., inspectors returned to find Resident 32 awake in bed again. The call light remained on the floor, inaccessible.
Two and a half hours later at 2:46 p.m., the resident was sleeping but the call light was still on the floor.
On the final day of inspection at 9:01 a.m., Resident 32 was sitting up in bed, awake and alert. The call light was still on the floor.
Two minutes later, the surveyor summoned a licensed practical nurse to the bedside. The LPN confirmed the call light was on the floor and acknowledged it was not accessible to the resident and should have been.
The facility's own policy from September 2022 states that residents must be provided with a means to call staff for assistance through a communication system. Each resident should have access to call staff directly from their bed, from toileting and bathing facilities, and from the floor.
For a resident with severe cognitive impairment who had fallen seven times in one month, the inaccessible call light meant no way to request help for toileting, transfers, or medical emergencies. The resident's conditions - including epilepsy and heart failure - could require immediate medical attention.
The violation occurred despite clear documentation in the resident's care plan about fall risk and the need to keep emergency communication within reach. Staff had been specifically directed to encourage call light use due to the resident's confusion, mobility problems and breathing difficulties.
The inspection found this represented a failure to reasonably accommodate the resident's needs and preferences, putting them at risk for harm.
Federal regulations require nursing homes to ensure residents can summon assistance when needed. For residents with cognitive impairment and multiple medical conditions, accessible emergency communication becomes even more critical to prevent serious injury or death.
The facility received a minimal harm citation, meaning the deficient practice had the potential to cause actual harm to residents but had not yet resulted in documented injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colfax Nursing and Rehab, LLC from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Colfax Nursing and Rehab, LLC in COLFAX, LA was cited for violations during a health inspection on August 27, 2025.
Each time, the resident was awake and alert but unable to summon help.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.