Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Colonial Skilled Nursing Facility Llc during CMS and state inspections, most recent first.
The facility did not ensure that care plan meetings with IDT participation were conducted and documented for five residents after their comprehensive MDS assessments. For each resident, there was no evidence of a care plan meeting or IDT review following the assessment, and the DON was unable to provide required documentation during the survey.
The facility did not have menu extensions or standardized recipes for mechanical soft diets, resulting in staff making ad hoc modifications to meals for several residents. Dietary staff substituted menu items, such as replacing tortillas with rolls, without standardized guidance, and residents expressed dissatisfaction with the substitutions. The Registered Dietitian confirmed the absence of appropriate menu extensions and recipes for these therapeutic diets.
The facility did not update its water management plan to reflect current team members, failed to maintain clean conditions in the laundry area, and did not disinfect blood pressure equipment after use. These lapses in infection prevention and control were observed during staff interviews, environmental tours, and direct care observations.
A resident with mild cognitive deficits who relied on a wheelchair for mobility was left with a broken wheelchair lock since admission. During meal observations, the resident's wheelchair repeatedly rolled away from the table, causing difficulty eating and food spillage. Staff and therapy confirmed awareness of the broken lock, but it remained unrepaired, impacting the resident's ability to safely participate in daily activities.
A resident with mild cognitive deficits was admitted without any assessment or assistance regarding advance directives, as required by facility policy. There was no documentation in the medical record of advance directives or related social services involvement, and staff interviews confirmed that the process was not completed for this admission.
A resident with mild cognitive deficits and tremors was not provided with timely adaptive equipment or interventions to support independent eating, despite repeated observations of significant food spillage and difficulty using standard utensils. Staff and therapy assessments failed to address the resident's needs during meals, and the facility lacked necessary adaptive feeding equipment, resulting in the resident eating very little and remaining hungry.
A resident who was dependent on staff for ADLs did not receive proper nail care as outlined in her care plan. Despite instructions for CNAs to check, trim, and clean fingernails on bath days, there was no documentation of nail care being provided or refused. Observations showed the resident's right-hand fingernails were overgrown and dirty, while the left hand was clean. Staff interviews revealed confusion about responsibility for nail care, and the issue persisted over multiple days.
A resident who was downgraded to nectar thick liquids continued to be served thin liquids by staff, including a CNA and COTAs, due to confusion over dietary orders and lack of communication. Despite a physician's order and facility policy requiring adherence to therapeutic diet modifications, the resident was repeatedly given the incorrect liquid consistency.
A resident who was cognitively intact and disliked a pureed diet was evaluated by Speech Therapy, which recommended a mechanical soft/ground texture diet. Despite this recommendation, the resident continued to receive inconsistent meals, sometimes pureed and sometimes mechanical soft, due to a lack of communication and failure to update the official diet order. Staff and the resident expressed confusion about the correct diet, and the DON confirmed that the SLP did not communicate the change to the necessary departments.
The facility did not consistently post accurate daily nurse staffing information, with missing staff numbers on several days and outdated information displayed on another day. The nurse assigned to the overnight shift was responsible for posting the information, but the required details were not included.
Failure to Document and Conduct Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings with interdisciplinary team (IDT) participation were conducted and documented for five residents following their comprehensive assessments. For each resident reviewed, there was no evidence in the clinical records of care plan meetings being held after the completion of their respective Minimum Data Set (MDS) assessments. Specifically, for one resident with progressive neurological conditions, the 5-day MDS assessment was completed, but there was no documentation of a care plan meeting or IDT review. The Director of Nursing (DON) was unable to provide sign-in sheets or other evidence of these meetings, citing missing documentation and unavailable staff. For other residents, records similarly lacked evidence of care plan meetings with IDT participation after their most recent MDS assessments. In one case, the most current care plan meeting on file predated the latest MDS assessment by several months. The DON acknowledged that documentation was kept on paper in a binder but was unable to produce the required evidence during the survey. The absence of documentation and IDT participation in care plan meetings was consistent across all five residents reviewed.
Failure to Provide Menu Extensions and Standardized Recipes for Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure that menus were developed and implemented for residents requiring a mechanical soft diet, as required by policy and regulation. Specifically, there were no menu extensions or standardized recipes for the mechanical soft diet, and staff relied on modifying regular menu items based on personal experience rather than following established guidelines. The Registered Dietitian (RD) confirmed that upon her hiring, she identified the absence of menu extensions for therapeutic and texture-modified diets, and that the facility was using menus from the Assisted Living Facility, which did not include necessary modifications. The Dietary Manager and Kitchen Manager both acknowledged that they did not have recipes or menu extensions for mechanical soft diets and instead made substitutions or modifications as they saw fit, such as replacing soft tortillas with rolls for residents on mechanical soft diets. During meal observations, residents on mechanical soft diets were served food items that were not consistent with the planned menu or their preferences, and there was no documentation or recipe to guide appropriate substitutions. For example, a resident expressed dissatisfaction when served a roll instead of a taco, and staff explained that mechanical soft diets could not include tortillas due to choking risks. The RD and dietary staff confirmed that there were no standardized recipes or menu extensions in use, and that the current practice was to adjust meals based on staff judgment rather than established dietary guidelines.
Infection Control Program Deficiencies and Environmental Hygiene Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several deficiencies in policy implementation and environmental hygiene. The water management plan was not updated to reflect the current program management team, with outdated names listed for the Executive Director, Maintenance Director, and Director of Nursing. Interviews with current staff revealed that the individuals listed in the plan no longer worked at the facility, and the current team members were either unaware of their roles or had not participated in relevant meetings. The plan had not been revised during the most recent program review, despite changes in personnel. Environmental observations in the laundry area revealed significant lapses in cleanliness and maintenance. The tops of two commercial dryers were heavily soiled with dust and were located near the sorting area for clean linens, creating a risk of contamination. Additionally, one washing machine was found to be in disrepair, rusty, soiled, and partially falling apart. A linen cart with clean linens was observed covered with a heavily soiled material, further compromising the cleanliness of items intended for resident use. These findings were acknowledged by facility staff during the survey. Infection control practices were also not followed during direct resident care. During medication administration, a registered nurse used blood pressure monitoring equipment to assess a resident's vital signs but failed to disinfect the equipment before returning it to the medication cart. This lapse in protocol was observed by the surveyor and contributed to the overall deficiency in infection prevention and control within the facility.
Failure to Provide Functional Wheelchair for Resident
Penalty
Summary
The facility failed to provide a functional wheelchair for a resident whose wheelchair lock had been broken since admission. The resident, who had mild cognitive deficits and required a wheelchair for mobility, was observed during multiple meal times to have difficulty remaining at the dining table due to the wheelchair rolling backward. This resulted in the resident having to reach further for food and spilling food during attempts to eat. Staff were observed repositioning the resident, but the issue persisted as only one side of the wheelchair could be locked, and the other lock was broken and nonfunctional. Therapy staff confirmed awareness of the broken lock since the resident's admission, with the usual therapist stating that maintenance was not available to fix the issue. The therapist also indicated that while she could repair wheelchairs, her caseload took priority. The broken wheelchair lock was directly observed by surveyors, and staff interviews confirmed the ongoing problem and lack of timely repair.
Failure to Assess and Assist with Advance Directives on Admission
Penalty
Summary
The facility failed to assess for or assist in the formulation of advance directives upon admission for a resident. Policy review indicated that on admission, the facility is required to determine if a resident has executed an advance directive and, if not, to determine whether the resident would like to formulate one. Additionally, the social worker or designee is responsible for completing an initial and quarterly assessment to identify any need for medically-related social services, including assistance with advance care planning and completion of advance directives. Record review for the resident in question showed no evidence of advance directives, no assessment for advance directives, and no documentation of assistance by social services regarding advance directives. The resident was admitted with mild cognitive deficits, as indicated by a BIMS score of 11, and was documented as being his own representative. During interviews, the DON stated that Admissions was responsible for assessing advance directives, while the BOM, who was also responsible for admissions and social services, explained that advance directive information is typically obtained from the hospital or previous facility, or by reaching out to the resident or their representative if not provided. However, for this resident, the BOM confirmed there was no documentation or evidence of advance directives in the medical record, and no assessment or assistance had been provided.
Failure to Provide Adaptive Equipment and Timely Interventions for Eating Independence
Penalty
Summary
The facility failed to implement timely interventions and provide adaptive equipment to maintain eating independence for a resident with mild cognitive deficits and physical limitations. The resident, who had a history of tremors and required setup assistance for eating, was observed repeatedly spilling food and struggling to eat independently during multiple meals. Despite an occupational therapy (OT) evaluation indicating the need to maximize independence with activities of daily living, there was no documentation of interventions or adaptive equipment being provided to address the resident's difficulties with eating. Observations revealed that the resident experienced significant food spillage, was unable to effectively use regular utensils and plates, and had difficulty keeping his wheelchair positioned at the table. Staff noted the resident's preference for independence but did not provide appropriate adaptive equipment or consistent assistance, resulting in the resident eating very little during meals and expressing continued hunger. The dietary manager confirmed that no adaptive feeding equipment was available in the facility, despite requests for such equipment for residents in need. Interviews with therapy and dietary staff indicated a lack of follow-through on orders for adaptive equipment and insufficient assessment of the resident's needs during mealtimes. The occupational therapy staff focused primarily on posture and trunk strengthening, overlooking the resident's functional challenges with self-feeding. Only after repeated observations and a new order for adaptive equipment was an assessment conducted, which confirmed the resident would benefit from items such as a plate guard, sippie cup, and weighted utensils.
Failure to Provide Proper Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was substantially to totally dependent on staff for all activities of daily living (ADLs) except eating due to a stroke affecting her left side, did not receive proper nail care as required by her care plan. The care plan specified that staff should check, trim, and clean the resident's fingernails on bath days and as necessary. Despite this, documentation from certified nursing assistants (CNAs), progress notes, and additional care plans lacked any record of nail care being provided or refused for this resident. Observations revealed that the resident's right-hand fingernails were significantly overgrown, extending nearly a centimeter beyond the fingertip, and had visible debris underneath, while the left hand was clean and trimmed. The resident, who was cognitively intact, initially stated she cared for her own nails but later acknowledged receiving help. Interviews with staff indicated confusion about who was responsible for nail care, with some believing hospice or activities staff provided it, while the care plan clearly assigned this responsibility to CNAs on bath days. The condition of the resident's nails remained unchanged over several days of observation.
Failure to Provide Physician-Ordered Liquid Consistency
Penalty
Summary
A deficiency occurred when the facility failed to provide a physician-ordered liquid consistency for a resident who had been downgraded to nectar thick liquids. The resident, initially admitted on a regular diet with thin liquids, was observed coughing while drinking thin liquids, prompting a downgrade to nectar thick liquids as ordered by the physician. Despite this order, the resident continued to be served thin liquids on multiple occasions. Staff members, including a CNA and two COTAs, provided the resident with thin juice, either due to confusion over the menu ticket or lack of awareness of the updated dietary order. The CNA served thin juice because the menu ticket listed both thin and nectar options, and she did not notice the nectar order. Both COTAs were unaware of the change to nectar thick liquids and provided regular juice to the resident during their interactions. The facility's policy required that all diet and texture modifications be physician-ordered and that nursing and dietary staff ensure correct diet trays are served. However, the failure to communicate the updated dietary order and ensure staff adherence resulted in the resident receiving the incorrect liquid consistency. The observations and staff interviews confirmed that the resident was repeatedly given thin liquids after the downgrade order, contrary to the physician's instructions and facility policy.
Failure to Implement and Communicate Diet Upgrade for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a recommended diet upgrade for a cognitively intact resident was implemented and properly communicated to staff. The resident, who disliked the pureed diet and expressed a preference for regular food, had been evaluated by Speech Therapy, which recommended a mechanical soft/ground texture diet with thin liquids. Despite this, the resident continued to receive inconsistent meals, sometimes receiving mechanical soft and other times pureed, as evidenced by meal tickets and staff observations. The resident voiced dissatisfaction and confusion regarding the diet provided, and staff were also unclear about the correct diet order. Record review and staff interviews revealed that the Speech Language Pathologist (SLP) had documented the diet upgrade in therapy notes, but the order was not updated in the resident's official diet orders. The Director of Nursing (DON) acknowledged that the SLP should have updated the orders if the diet was changed, but stated that the SLP did not communicate the change to nursing or dietary staff. This lack of communication and failure to update the resident's diet order resulted in the resident not consistently receiving the appropriate diet as recommended by therapy.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted as required. Observations over four days revealed that the posted staffing information did not include the actual number of nursing staff on three days, and on one day, the information displayed was for the previous day rather than the current date. Photographic evidence was obtained to support these findings. During an interview, it was confirmed that the nurse working the overnight shift was responsible for completing and posting the staffing form, but the form did not contain all the required information.
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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 West Palm Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westgate Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Darcy Hall Of Life Care | 1.4 mi | ★★★★★ | 4 | 2 |
| Palm Garden Of West Palm Beach | 1.4 mi | ★★★★★ | 4 | 0 |
| Lakeside Health Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Joseph L Morse Health Center Inc The | 1.8 mi | ★★★★★ | 1 | 0 |
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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.