Deficiencies (last 2 years)
Deficiencies (over 2 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
55 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Sep 12, 2025
Visit Reason
Surveyor conducted a complaint investigation at A Colfax Senior Living LLC.
Findings
The complaint was unsubstantiated and no violations were identified.
Complaint Details
The complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 25, 2025
Visit Reason
A complaint investigation, self-report investigation, and verification visit were conducted to determine if A Colfax Senior Living LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD) #DBX313 for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $1,300 was imposed for identified violations, with a reduced forfeiture option of $845 if not appealed. The licensee is ordered to develop and implement corrective measures and provide training to staff within 45 days.
Complaint Details
The visit was complaint-related, involving a complaint investigation, self-report investigation, and verification visit to assess compliance with statutory and administrative requirements for community-based residential facilities.
Report Facts
Forfeiture amount: 1300
Reduced forfeiture amount: 845
Forfeiture amount: 300
Forfeiture amount: 1000
Days to achieve compliance: 45
Days to provide notice to legal representatives: 7
Days to request extension: 10
Revisit fee: 200
Days to pay forfeiture: 10
Days to pay revisit fee: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Aug 25, 2025
Visit Reason
The surveyor conducted a complaint investigation, verification visit, and self-report investigation at A Colfax Senior Living LLC. The complaint was unsubstantiated.
Findings
Two violations were identified, including a repeat deficiency. One violation involved failure to implement Resident 3's individual service plan related to elopement risk, and the other involved inadequate health monitoring for Residents 1 and 2, including failure to monitor post-hospital vitals and daily weight as ordered.
Complaint Details
The complaint investigation was unsubstantiated. The visit included a verification and self-report investigation. A $200 revisit fee was assessed under statutory provisions.
Deficiencies (2)
| Description |
|---|
| Failure to implement Resident 3's individual service plan regarding elopement risk; WanderGuard device was not in place as required. |
| Failure to provide adequate health monitoring services for Residents 1 and 2, including lack of physician notification after Resident 1's vomiting and failure to monitor Resident 2's daily weight as ordered. |
Report Facts
Revisit fee: 200
Census: 53
Deficiencies identified: 2
Resident 2 weight monitoring days: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding Resident 3's WanderGuard and health monitoring deficiencies |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding Resident 3's WanderGuard and health monitoring deficiencies |
| Caregiver C | Caregiver | Interviewed about elopement risk and WanderGuard use for Resident 3 |
| Assistant Administrator D | Assistant Administrator | Found Resident 3's WanderGuard device and reported it had been cut off |
| Dining Director E | Dining Director | Observed Resident 1 vomiting and reported to caregivers |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Nov 26, 2024
Visit Reason
The surveyor conducted a complaint investigation and verification visit at A Colfax Senior Living LLC. The complaint was unsubstantiated, but two violations were identified, both repeat deficiencies from a prior inspection dated 07/22/2024.
Findings
Two violations were found: 1) A lead caregiver did not complete required Department-approved medication training prior to administering medications, and 2) the provider failed to adequately monitor the health of residents, including bowel movements, oxygen saturation, and post-fall vital signs, resulting in repeat violations.
Complaint Details
The complaint investigation was unsubstantiated. Two violations were identified, both repeat deficiencies from a prior inspection dated 07/22/2024.
Deficiencies (2)
| Description |
|---|
| Lead Caregiver E did not complete Department-approved medication training prior to assuming medication responsibilities. |
| Provider did not monitor the health of 3 of 4 sampled residents, including failure to monitor bowel movements, oxygen saturation, and post-fall vital signs. |
Report Facts
Revisit fee: 200
Census: 50
Number of violations: 2
Number of times oxygen saturation below 90%: 17
Days without bowel movement: 10
Days without bowel movement: 11
Falls: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lead Caregiver E | Lead Caregiver | Named in medication training deficiency for not completing required medication administration course. |
| Executive Director A | Executive Director | Interviewed and confirmed lack of evidence for medication training completion by Lead Caregiver E. |
| Regional Registered Nurse B | Regional Registered Nurse | Interviewed regarding medication training and health monitoring deficiencies. |
| Community Nurse C | Community Nurse | Interviewed regarding medication training assumptions and health monitoring procedures. |
| Vice President of Clinical Operations D | Vice President of Clinical Operations | Interviewed regarding provider's policies and procedures related to deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 26, 2024
Visit Reason
A complaint investigation and verification was conducted on 2024-11-26 to determine if A Colfax Senior Living LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #DBX312) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $1,840 for specific code violations.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. The Department found violations and issued a Statement of Deficiency and Notice of Violation.
Deficiencies (2)
| Description |
|---|
| Violation of DHS Code 83.20(2)(a)-(d) |
| Violation of DHS Code 83.38(1)(g) |
Report Facts
Forfeiture amount: 400
Forfeiture amount: 1440
Total forfeiture amount: 1840
Reduced forfeiture amount: 1196
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William R. Gardner | Assisted Living Regional Director | Contact person for questions about the letter |
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 22, 2024
Visit Reason
A complaint investigation was conducted on 07-22-24 to determine if Colfax Senior Living LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department found violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Statement of Deficiency #DBX311 and imposed a total forfeiture of $7,500. The licensee was ordered to comply immediately with requirements related to supervision, health monitoring, and pressure injury prevention, including development of written procedures and staff training.
Complaint Details
The visit was a complaint investigation concluded on 07-22-24 to assess compliance with applicable statutes and administrative codes. Violations were substantiated as indicated by the issuance of the Statement of Deficiency #DBX311.
Deficiencies (3)
| Description |
|---|
| Failure to ensure the administrator supervises daily operation and ensures provision of services to meet residents’ physical and mental health needs. |
| Inadequate health monitoring procedures including documentation, notification, timely medical care, and service provision. |
| Insufficient pressure injury prevention including risk assessment, treatment, monitoring, notification, timely medical care, service plan review, and medical record standards. |
Report Facts
Forfeiture amount: 7500
Reduced forfeiture amount: 4875
Forfeiture breakdown: 600
Forfeiture breakdown: 200
Forfeiture breakdown: 400
Forfeiture breakdown: 400
Forfeiture breakdown: 1200
Forfeiture breakdown: 800
Forfeiture breakdown: 1100
Forfeiture breakdown: 2800
Inspection Report
Complaint Investigation
Census: 41
Capacity: 58
Deficiencies: 9
Jul 10, 2024
Visit Reason
The Department conducted a complaint investigation at A Colfax Senior Living LLC due to multiple complaints related to resident care and treatment, including injuries of unknown origin, failure to notify physicians and legal representatives of significant changes, and inadequate staff training.
Findings
The investigation substantiated 3 of 5 complaints and identified 12 deficiencies including failure to investigate injuries of unknown origin, failure to notify physicians and legal representatives of significant changes, inadequate staff training, failure to provide prompt and adequate treatment, incomplete resident assessments, and failure to update individual service plans with changes in condition.
Complaint Details
Three of five complaints were substantiated. Complaints included failure to investigate injuries of unknown origin, failure to notify physicians and legal representatives of significant changes, inadequate staff training, and failure to provide adequate care.
Deficiencies (9)
| Description |
|---|
| Failure to investigate injuries of unknown origin, including unexplained skin tear on Resident 4. |
| Failure to immediately notify Resident 1's legal representative and physician about significant changes in skin and pain level, and failure to notify Resident 2's physician about oxygen saturation and leg swelling changes. |
| Failure to notify the Department within 7 days after a change in administrator. |
| Administrator did not adequately supervise daily operations to ensure proper care, treatment, and resident rights. |
| Failure to ensure staff completed required orientation and training, including standard precautions, fire safety, first aid, medication administration, and client group specific training. |
| Failure to provide prompt and adequate treatment to Resident 1 after a burn injury caused by spilled hot coffee, resulting in delayed medical care and hospitalization. |
| Failure to complete comprehensive assessments after significant changes in condition for Residents 1 and 3. |
| Failure to update individual service plans for Residents 1, 2, and 4 to reflect changes in condition and care needs. |
| Failure to monitor health and arrange for medical intervention for Residents 1, 2, 3, and 5, including failure to monitor skin conditions, oxygen saturation, and weight. |
Report Facts
Deficiencies identified: 12
Resident census: 41
Licensed capacity: 58
Oxygen saturation readings below 90%: 22
Pressure injury size: 8
Pressure injury size: 7
Pressure injury size: 0.4
Pressure injury size: 12
Pressure injury size: 4
Pressure injury size: 2.9
Pressure injury size: 1.5
Resident 3 weight increase: 21.8
Resident 5 weight: 250.2
Resident 5 weight: 248.8
Resident 5 weight: 252
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver J | Lead Caregiver | Named in burn incident involving Resident 1 and failure to follow first aid procedures |
| Director of Nursing B | Director of Nursing | Named in multiple findings including failure to investigate injuries, failure to notify physicians, and inadequate assessments |
| Administrator A | Administrator | Named in failure to notify department of administrator change and inadequate supervision |
| House Manager F | House Manager | Named in failure to notify nurse of Resident 1's pressure injury and incomplete assessments |
| Vice President C | Senior Vice President | Named in interview regarding training and supervision deficiencies |
| Vice President of Clinical Services D | Vice President of Clinical Services | Named in interview regarding training and supervision deficiencies |
| Regional Nurse E | Regional Nurse | Named in interview regarding training and supervision deficiencies |
| Caregiver I | Caregiver | Named in training deficiencies and burn incident |
| Caregiver K | Caregiver | Named in training deficiencies and burn incident |
| Caregiver O | Caregiver | Named in documentation of skin breakdown |
| Caregiver Q | Caregiver | Named in documentation of pressure injury blister |
| Caregiver R | Caregiver | Named in incident report of Resident 1 found on floor |
| Home Health Registered Nurse L | Home Health Registered Nurse | Named in assessment and notification of Resident 1's burn injury |
| Medical Doctor M | Medical Doctor | Named in hospital documentation of Resident 1's burn injury |
| House Manager U | House Manager | Named in failure to notify nurse of Resident 2's wound and low oxygen saturations |
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