Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide accurate, palatable meals at proper temperatures. Six residents reported that their food was often cold and did not match the meal tickets. During two observed lunch meals, one resident received hot and cold items measured outside the facility’s required temperature ranges, and another resident’s original tray was missing multiple ordered food items and adaptive equipment. The replacement tray for that resident also lacked ordered gravy, did not have the turkey cut as specified, provided a divided plate instead of a scoop plate, and included regular milk instead of a prescribed diet shake. The Food Service Director confirmed that staff were responsible for checking trays against meal tickets, acknowledged ongoing resident complaints about missing items, and stated the required temperature standards for hot and cold foods.
The facility failed to ensure residents had an accessible grievance process for all residents. Surveyors found no grievance forms available at the box, no prominent postings explaining how to file grievances orally or in writing, no clear way to file anonymously, and residents said they did not know who the grievance officer was or where forms were located. Resident council concerns were repeatedly brought to the Administrator without follow-up, and one resident reported filing a grievance months earlier without hearing back. Staff gave inconsistent descriptions of how grievances were handled, including referrals to the ombudsman, nursing notes, or forms kept in the SW office or behind the nurse's station.
A facility failed to maintain adequate nutrition support for two residents at risk for malnutrition and weight loss. One resident with failure to thrive and cerebral palsy had missed and undocumented weights, significant weight loss, no timely reweight after a large decline, and no documented provider response to the weight loss. Another resident with dementia and diabetes did not consistently receive ordered supplement support when Ensure Plus was substituted without RD notification and was observed at meals with little assistance or encouragement, resulting in poor intake.
Failure to notify the physician of a significant change in condition: A resident with CHF, CKD, HTN, and facial edema had an 11.8-lb weight gain in 9 days, but no documented reweight or provider notification was found. Nursing notes later showed worsening edema, inability to open the eyes, and difficulty breathing, and the resident was sent to the hospital for acute angioedema with airway compromise and fluid overload.
Failure to Address Repeated Refusals of Ordered Respiratory Medications: A resident with COPD, cerebral palsy, and severely impaired cognition repeatedly refused ordered inhaler and nebulizer treatments. The MAR showed numerous refusals of budesonide and ipratropium-albuterol, but there was no documented evidence that the MD was notified, that the consultant pharmacist identified the irregularities during monthly med reviews, or that the care plan addressed the refusals.
A resident with recent critical illness, respiratory needs, a modified diet, and abdominal wound/drain care was admitted without a timely RN admission assessment, and ordered treatments, monitoring, and labs were not documented as completed. The chart also lacked evidence of BiPAP orders, wound/drain assessments, or incentive spirometry. When the resident left AMA, there was no documentation of who they left with, whether education was provided, or whether a medical provider was notified.
Missed ordered wound care for a resident with dementia, FTT, a Stage 4 heel ulcer, an unstageable heel ulcer, and MASD. The resident had care plan interventions and physician orders for skin prep, zinc cream, and specific heel and foot dressings, but the TAR showed multiple missed treatments across several shifts by LPNs. An LPN said wound care sometimes could not be completed when working alone because of medication pass duties, and the RN unit manager said missed care was not documented or reported to them.
A resident with cerebral palsy, dysphagia, Alzheimer's disease, and severe cognitive impairment depended on PEG tube feeding for nutrition and hydration. Staff did not verify and follow the ordered Jevity 1.5 rate and water flush orders, the feeding was observed running at 50 mL/hour instead of 55 mL/hour, the formula bottle was left undated, and the pump monitor was unclean with brownish streaks. An LPN later found the formula empty, restarted the feeding at the wrong rate, and staff confirmed they had not checked the orders before providing care.
A resident with ESRD received hemodialysis at an outside dialysis center, but the facility did not document ongoing pre- and post-dialysis assessments, including access site checks, or consistently review dialysis communication reports. The resident’s care plan addressed the dialysis port, and staff said pre-dialysis vitals, access site monitoring, and review of return information were part of the process, but multiple dialysis treatments lacked documented assessments and several communication forms were missing from the record.
A resident with bipolar disorder with psychotic features, anxiety, depression, and paranoia had repeated behavioral outbursts, including yelling, throwing items, and punching walls, but the care plan was not fully person-centered or tailored to known triggers and coping skills such as Bible study, prayer, music, and preferred activities. Staff also did not document coordination or follow-up with the resident’s outside behavioral health providers, despite ongoing monthly visits and continued agitation, and there was no documented social work follow-up after a wall-punching incident.
Survey results were not posted in a readily accessible location for resident review, and there was no posted notice showing where the previous three years of survey reports could be found. Residents said they had never seen the survey results, and staff gave conflicting answers about where the reports were kept, including the DON's office and a binder near the front entrance.
Failure to Post Required Daily Nurse Staffing Information: The facility did not post required daily nurse staffing information in a prominent, readily accessible location, and when staffing sheets were posted they did not include the resident census or the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. The Nursing Scheduler stated they were responsible for posting day and evening staffing, while the nursing supervisor posted night and weekend staffing, and they were not aware the census and actual hours worked were required.
A resident with stroke, right-sided paralysis, and intact cognition had a Medicare Part A skilled stay that ended, but the facility did not document timely delivery of the required CMS 10123 notice or the CMS 10055 ABN. The Rehab Director said they took over the task without training, and the Administrator acknowledged the facility had trouble locating these notices and that this was a deficient practice.
A resident with serious infections did not receive or have documented several scheduled IV antibiotic doses, as required by physician orders. MAR entries were left blank for multiple administrations, and there was no evidence in progress notes or provider notification regarding the missed doses. Staff interviews revealed confusion about responsibility for IV medication administration and documentation, and facility leadership confirmed that blank MAR entries constituted medication errors, but no investigation or provider notification was documented.
A resident receiving IV vancomycin for serious infections did not have required vancomycin trough levels drawn as ordered, and the only recorded trough was not performed at the correct time. Staff interviews revealed confusion about lab scheduling and timing, and there was no documentation that the necessary labs were completed or communicated to the pharmacy or consultant pharmacist.
A resident with multiple health conditions did not receive critical medications as ordered due to delays in corporate approval and communication failures within the facility. The resident's medications, including those for Parkinson's, diabetes, and respiratory issues, were unavailable on multiple occasions, and there was no evidence that providers were notified. This deficiency in medication management led to worsening symptoms for the resident.
The facility failed to ensure a proper grievance process, as residents were unaware of the grievance officer and did not receive follow-up on grievances. A resident with cerebral palsy reported discomfort with CNAs' behavior, but the grievance resolution was incomplete, with only one CNA re-educated and the resident's care preferences not fully addressed. Staff interviews revealed inconsistencies in grievance handling, highlighting a deficiency in the process.
The facility failed to adhere to food safety standards, with improper cooling of hot food, a malfunctioning dishwasher, and outdated food in the cooler. Observations revealed rice and other items not cooled properly, incomplete cooling logs, and a dishwasher with inadequate temperatures and sanitizer levels. Outdated food items were also found, indicating lapses in monitoring and adherence to protocols.
A survey revealed that a facility failed to properly label and store medications, including insulin pens and eye drops, across multiple medication carts. Medications lacked resident-specific identifiers and opened/discard dates, and some were expired. Staff interviews indicated a lack of knowledge about medication expiration and inadequate documentation of checks, contributing to these deficiencies.
A facility failed to maintain effective infection control practices for a resident with clostridium difficile. Staff did not consistently wear required PPE or perform hand hygiene when entering or exiting the resident's room, despite signage indicating contact precautions. Interviews revealed a lack of understanding and adherence to protocols, with the DON confirming the importance of following isolation room procedures.
A resident with a history of stroke and infections was prescribed antibiotics for an elevated white blood cell count, but the facility failed to notify the resident's representative as required by their policy. Despite the initiation of Doxycycline and Ceftriaxone treatments, there was no documentation of notification, and interviews confirmed the lapse.
A resident with visual impairment and depression was not provided with a large print Bible or glasses, which were necessary for their participation in activities. The resident's care plan documented these needs, but staff were unaware of the missing items. The Activities Director acknowledged the oversight, and the deficiency was noted during the survey.
Two residents with pressure ulcers did not have their low air loss mattresses set according to their current weights, and the settings were not documented in their care plans or physician orders. One resident with a Stage 4 ulcer had their mattress set too firm, while another resident with an unstageable ulcer had unclear mattress settings. Staff interviews revealed confusion about responsibility for setting and monitoring the mattresses.
A resident with dysphagia was observed eating alone in their room without supervision, despite being care planned for line-of-sight supervision during meals. Facility policies required supervision for residents on altered diets to ensure safety, but staff failed to adhere to these protocols, as confirmed by interviews with a CNA, RN Unit Manager, and Speech and Language Pathologist.
A resident requiring BiPAP therapy did not receive proper respiratory care as the facility failed to clean and maintain the equipment per professional standards. Observations showed the mask was dirty and improperly maintained, with no documented cleaning schedule or physician orders. Staff interviews confirmed the lack of proper documentation and adherence to care protocols, potentially leading to respiratory infections.
A resident with end-stage renal disease did not receive proper pre- and post-dialysis evaluations at an LTC facility. The facility failed to document vital signs and access site assessments, and the communication book with the dialysis center was incomplete and outdated. Staff interviews revealed confusion over documentation responsibilities, compromising the resident's safety.
The facility failed to provide meals at appropriate temperatures and with adequate flavor, as observed during a survey. Meals served on two occasions were below temperature standards, bland, and contained foreign substances. Residents reported missing items and unappetizing food. Staff interviews revealed issues with menu changes and communication, leading to inaccurate meal service.
Failure to Provide Accurate, Palatable Meals at Proper Temperatures
Penalty
Summary
The facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional needs, as evidenced by multiple issues with meal temperatures, tray accuracy, and missing adaptive equipment during surveyor observations and resident interviews. Facility policy required that all meals be checked for accuracy against meal tickets, that hot foods be maintained above 140°F and cold foods below 41°F, and that trays be verified before leaving the kitchen. During a resident group meeting, six anonymous residents reported that their food was often cold and that the items on their trays did not match the meal tickets. These resident reports were corroborated by direct observations of two lunch meals. During a lunch observation on one unit, a resident’s tray was the last served and food temperatures were measured and verified with the Regional Director of Food Operations: the ziti was 133°F, the broccoli 110°F and cool to taste, the garlic bread 100°F, the coffee 133°F, and the pineapple 68°F, all outside the facility’s stated acceptable ranges for hot and cold foods. On another unit during a separate lunch observation, a resident’s tray was identified by a CNA as incorrect and missing multiple ordered items, including turkey, gravy, creamed spinach, cottage cheese, chilled peaches, a diet house shake, Mrs. Dash seasoning, margarine, and a scoop plate; measured temperatures showed stuffing at 125.1°F, carrots at 110.2°F, and water at 62.8°F. When a replacement tray was delivered, it was still missing gravy, the turkey was not cut as directed on the meal ticket, the resident received a divided plate instead of the ordered scoop plate, and regular milk was provided instead of the diet house shake. In an interview, the Food Service Director acknowledged that all dietary staff were responsible for meal ticket accuracy, that residents had been complaining of missing items for months, and confirmed the required temperature standards for hot and cold foods.
Grievance process not accessible or consistently managed
Penalty
Summary
The facility failed to ensure a process was in place for residents to have grievances addressed appropriately for 79 of 79 residents. Surveyors found that information on how to file a grievance and grievance forms were not available to residents, and the facility did not have a process for residents to file an anonymous grievance. The facility policy stated residents and their representatives had the right to file grievances without discrimination or reprisal, grievances could be submitted orally or in writing, and grievances may be filed anonymously, with written information provided on admission and responses given within seven working days. During observations at the main entrance, surveyors saw a metal grievance box on the wall across from the receptionist with a sign directing residents to place grievances in the box or submit them to social work or a department manager/supervisor. However, there were no forms with the box and no postings in prominent locations throughout the facility explaining the right to file grievances orally or in writing, the right to file anonymously, or the contact information for the grievance official. Residents in the group meeting stated they did not know whether grievance forms existed or where to find them, did not know their right to file anonymously, and did not know who the grievance officer was. Resident council concerns were also not addressed beyond being brought to the Administrator, and residents reported the same concerns carried from meeting to meeting without resolution. One resident stated they had filed a grievance six to seven months earlier and had not heard anything back. Staff interviews showed inconsistent understanding of the grievance process: one CNA referred residents to an ombudsman pamphlet, an LPN said grievances could be verbal and documented in a nursing note, the ADON said residents could not file anonymously because they would have to ask for the form, and the DSW said blank forms were kept behind the nurse's station and residents had to ask for them. The DSW also stated they were the grievance officer and gatekeeper, but later said they did not have a key to the grievance box and did not know who checked it.
Failure to Maintain Nutrition and Meal Support
Penalty
Summary
The facility failed to ensure adequate nutrition and fluid support for two residents who were identified as being at risk for malnutrition and weight loss. One resident had diagnoses including adult failure to thrive and cerebral palsy, was severely cognitively impaired, required partial/moderate assistance with eating, and was ordered a puree diet with nectar thick liquids. The resident’s record showed significant weight loss over time, including a 10.8-pound loss in one month and later a 16.4-pound loss in one month, with several missed or undocumented weights and no timely reweight after the large loss. Weekly weights were discontinued, and there was no documented evidence that a medical provider was notified of or addressed the resident’s significant weight loss during the period reviewed. The same resident’s nutrition records showed ongoing high nutrition risk, malnutrition criteria, fluctuating weights, and repeated dietitian follow-up. The resident was ordered nutritional shakes and later mirtazapine for appetite stimulation, but the record did not show timely provider involvement when the severe weight loss occurred. Survey observations showed the resident eating in the dining room with assistance, consuming some items but refusing others, and later consuming a full lunch tray. Staff interviews indicated weights were supposed to be obtained as ordered and refusals documented, but the unit manager stated nursing did not notify medical when significant weight changes occurred, and the dietitian stated the resident was supposed to be weighed weekly but was not and reweights were not obtained as requested. A second resident with dementia, adult failure to thrive, and diabetes was assessed as severely cognitively impaired and required supervision or touching assistance with eating. The care plan directed assistance with feeding and monitoring meal consumption, and the resident was ordered Ensure Plus with meals. During observation, the resident sat with head down and initially received no assistance or encouragement to eat; one CNA asked if the resident was going to eat and walked away, another briefly asked what the resident wanted to eat and then left to assist another resident, and the resident ultimately consumed only 0-25% of food and fluids. Staff interviews confirmed the resident sometimes needed more assistance than usual, ate better when assisted, and that the kitchen had substituted Mighty Shakes for Ensure Plus without the dietitian being notified.
Failure to Notify Physician of Significant Weight Gain and Worsening Edema
Penalty
Summary
The facility failed to consult the physician when Resident #3 had a significant change in physical status. Resident #3 had diagnoses including heart failure, chronic kidney disease stage 4, and hypertension, and the record showed intact cognition and a therapeutic diet. The resident’s condition included facial edema, renal failure, and later fluid overload, but there was no documented evidence that the physician was notified when the resident developed a significant weight gain or worsening edema. The resident’s weight record showed 166.8 pounds on 02/01/2026 and 178.6 pounds on 02/10/2026, an 11.8-pound gain in nine days. There was no documentation that a reweigh was obtained or that the medical provider was notified of the severe weight gain. The registered dietitian documented on 02/11/2026 that the resident’s weight had increased by more than five pounds and requested a reweight, but there was still no documented evidence that the reweight occurred or that the provider was informed. Subsequent nursing notes documented worsening edema, including increased facial edema, 2+ edema, swollen lower extremities, and later inability to open the eyes with difficulty breathing. On 02/24/2026, the resident had 4+ bilateral lower extremity edema and was sent to the hospital for acute angioedema with airway compromise and fluid overload secondary to chronic kidney disease with pulmonary congestion. The record also showed earlier hospitalization for facial and leg swelling, and survey interviews indicated weights were supposed to be obtained as ordered and significant weight changes discussed, but Resident #3’s weights were not obtained as ordered and provider notification was not documented.
Failure to Address Repeated Refusals of Ordered Respiratory Medications
Penalty
Summary
Services provided by the nursing facility failed to meet professional standards of clinical practice for Resident #7, who had diagnoses including chronic obstructive pulmonary disease and cerebral palsy. The 02/22/2026 MDS documented severely impaired cognition, no behavioral symptoms, and the need for moderate assistance with all activities of daily living. The resident’s care plan addressed an alteration in the respiratory system related to COPD, smoking, shortness of breath while lying flat, and a lung nodule, with interventions to administer nebulizer treatments and medications per orders and to observe vital signs and report abnormalities to the medical provider. Physician orders included ipratropium-albuterol inhalation three times daily and budesonide inhalation suspension twice daily. The March 2026 MAR and April 2026 MAR documented repeated refusals of both respiratory medications on numerous dates, with only occasional doses accepted. The record contained no documented evidence that the physician was notified of the refusals or reviewed the MARs during monthly visits, no documented evidence that the consultant pharmacist identified the medication irregularities during monthly medication regimen reviews, and no documented evidence of a care plan related to the resident’s medication refusals.
Failure to complete admission assessment, ordered care, and AMA documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for one resident who was admitted after a prolonged hospitalization for critical illness. The resident’s hospital discharge summary documented multiple serious diagnoses, including atrial fibrillation/flutter, acute respiratory failure, stomach perforation, upper gastrointestinal hemorrhage, acute kidney failure, ischemic stroke with dysphagia and expressive language disorder, and the need for oxygen, nocturnal BiPAP, a modified diet, and wound care for a surgical abdominal wound. After arrival at the facility, there was no documented evidence of a nursing progress note addressing the admission and no documented evidence that a registered nurse completed an admission assessment until the day the resident left against medical advice. The record also showed that ordered care and monitoring were not completed. Physician orders included incentive spirometry, wound care, laboratory testing, oxygen therapy, and Jackson Pratt drain care, but there was no documented evidence that incentive spirometry was provided, that the abdominal wound or drain site was monitored, that dressing changes around the drain site were performed, or that the ordered diagnostic blood tests were collected. The record further noted there was no documented evidence of a physician order for BiPAP use at night, and facility staffing records showed there was no registered nurse working the evening or night shifts on the resident’s admission date. When the resident left against medical advice, the documentation did not show who the resident left with, whether education about the medical condition, diet, medications, wound care, drain care, oxygen therapy, follow-up care, or risks of leaving AMA was provided, or whether a medical provider was notified at the time. Social work learned of the departure later, and the physician documented the resident left AMA only in a late entry after the fact. Interviews with nursing, social work, the DON, and the physician confirmed the resident was not assessed by a registered nurse within 24 hours of admission and that the medical team was not notified in real time when the resident left.
Missed Ordered Wound Care for Resident With Multiple Pressure Injuries
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident with dementia, adult failure to thrive, a Stage 4 pressure ulcer of the left heel, an unstageable pressure ulcer of the right heel, and moisture associated skin damage. The resident’s care plan included daily monitoring of dressings, heel protectors, and weekly wound assessment, and physician orders were in place for multiple wound and skin treatments, including skin prep to the toes and left second toe, zinc cream to the buttocks, and specific cleansing and dressing regimens for the left heel, right heel, and left dorsal foot. The April 2026 Treatment Administration Record showed multiple missed treatments. Skin prep to the tops of the toes on both feet and to the left second toe was not completed on several day shifts by two LPNs. Ordered wound care for the left heel, right heel, and left dorsal foot was not completed on one evening shift by an LPN. Ordered zinc cream to the buttocks for moisture associated skin damage was also not completed on multiple shifts by two LPNs and another LPN. During interview, one LPN stated that if wound care was not signed off in the TAR, it may not have been done, and that when working alone they were busy with medication pass and sometimes could not complete wound care before leaving. The RN unit manager stated all wound care should be completed as ordered and that if it was not documented in the TAR, it meant it was not completed; they also stated they were not notified of the missed wound care. The wound nurse practitioner stated they relied on nursing report rather than facility documentation and were not aware of open areas on the resident’s buttocks, though they stated the nurses should have been completing the wound care as ordered.
Tube Feeding and Flush Orders Not Followed
Penalty
Summary
The facility failed to ensure appropriate care for a resident who received nutrition and hydration through a PEG tube. The resident had cerebral palsy, dysphagia, Alzheimer's disease, severely impaired cognition, and was dependent on tube feeding for nutrition. The care plan directed staff to administer tube feeding and water flushes as ordered, and physician orders specified Jevity 1.5 at 55 mL/hour for 20 hours daily, along with ordered free water flushes and a liquid protein supplement. Observations showed the tube feeding was not infusing at the ordered rate and the resident did not receive the ordered water flushes as prescribed. On multiple observations, the pump displayed 50 mL/hour rather than 55 mL/hour. On one observation, the tube feeding bottle was hanging without a date or time, and the pump monitor was unclean with brownish streaks. Later, the pump alarmed because the formula was empty. LPN #6 found the empty bottle, turned off the pump, and then returned with a new bottle, dated the bottle and syringe, flushed the PEG tube with 60 mL of water, and restarted the pump at 50 mL/hour. Interviews confirmed staff did not verify the physician orders before administering the tube feeding and flushes. LPN #6 stated they did not review the resident's tube feeding or water flush orders before giving care. The unit manager stated all tube feeding and flush orders should be followed and reviewed before administration, and the NP and RD stated they expected staff to follow the orders and notify them if the resident did not receive tube feeding or flushes as ordered. The RD also stated the resident remained at high nutritional risk.
Dialysis Assessments and Communication Not Completed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with end-stage renal disease who received hemodialysis three times a week at a community-based dialysis center. The resident was cognitively intact and had a care plan that included monitoring the right upper chest dialysis port for bleeding or infection, but the plan did not include pre- and post-dialysis assessments. A physician order later documented the need for dialysis three times weekly, pre- and post-dialysis assessments, and monitoring of the dialysis site every shift. There was no documented evidence that post-dialysis information was reviewed for all dialysis treatments between 03/16/2026 and 04/13/2026. The record also lacked documented access site assessments on multiple dates before dialysis and lacked documented post-dialysis access site assessments on multiple dates after dialysis. In addition, several dialysis communication reports were missing from the medical record. During observation, the resident had a hemodialysis access site to the right upper chest with a clean, intact dressing. Staff interviews stated that pre-dialysis vital signs and access site checks were to be completed, dialysis communication forms were to be reviewed on return, and access sites were to be monitored every shift, with concerns reported to the nursing supervisor.
Behavioral Health Care and Care Planning Deficiencies
Penalty
Summary
The facility failed to ensure that Resident #49 received necessary behavioral health care and services to support the resident’s highest practicable physical, mental, and psychosocial well-being. Resident #49 had diagnoses including bipolar disorder with psychotic features, cerebral palsy, and anxiety, and the record showed ongoing behavioral disturbances such as yelling, throwing things, punching walls, accusing others of being verbally aggressive, and frequent disagreements with staff and other residents. The resident’s MDS documented intact cognition, moderate depression, no behaviors, and use of antipsychotic and antianxiety medications, while the care plans described mood-related behaviors, paranoia, and attention-seeking, along with interventions such as medication administration, redirection, and behavior monitoring. The resident’s PASRR Level II identified a history of bipolar disorder with psychotic features, depression, paranoia, irritability, hopelessness, sleep trouble, and triggers including boredom, feeling unheard, and not getting their way. It also noted coping strategies such as prayer, Bible study, and engagement in preferred activities like football, video games, music, cars, and dogs, and called for a written person-centered psychiatric plan of care that addressed symptoms, triggers, early warning signs, and personalized coping skills. However, the facility did not document a personalized care plan that incorporated these specific triggers, coping strategies, and supports, and staff interviews confirmed that the interventions in the care plan were not fully person-centered. The record also showed a lack of coordination with outside behavioral health services. Resident #49 reported monthly behavioral health visits from December 2025 through March 2026, but there was no documented evidence of consultations, follow-ups, or collaboration from outside behavioral health appointments during that period. After the resident punched a wall and became agitated, there was no documented follow-up by social services. During later encounters, the resident continued to display agitation and behavioral dysregulation, including approaching the nurses’ station angrily and throwing a hat, while staff described the resident as having daily behaviors and needing one-to-one attention, yet the facility did not document the outside behavioral health communication that was expected to support continuity of care.
Survey Results Not Readily Available for Resident Review
Penalty
Summary
The facility failed to ensure that the results of the most recent Federal and State surveys were posted in a place readily accessible to individuals who wished to examine them without having to ask for them. The report states that the facility did not provide records for the standard health survey results or any complaint survey results, and there was no posted notification of the availability of the previous three years of survey reports. During an anonymous resident group meeting, six residents stated they had never seen any previous survey results and did not know where they were located. During facility walk-throughs, surveyors found no posted notification of the availability of survey reports and no surveys readily available for review. Staff interviews showed uncertainty about where the survey results were kept: a CNA did not know how residents could review them, an LPN thought they were in the DON's office, the ADON said they would have to ask the DON, and the DON stated they thought there was a binder of previous survey results on the bulletin board near the front entrance.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing information was posted daily at the beginning of each shift in a prominent location readily accessible to residents and visitors. On 04/14/2026, the daily nurse staffing information was not posted in the main lobby, on the main entrance doors, or down the main hallway between both units. The facility policy, Posting Direct Care Daily Staffing Numbers, stated the posting should include the facility name, the date, the resident census at the beginning of the shift, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift. The staffing information that was posted on 04/15/2026, 04/16/2026, and 04/17/2026 was located in a clear plastic frame in the main hallway across from the Administrator's office, but it did not include the resident census or the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. During interview, the Nursing Scheduler stated they were responsible for making the nursing schedule and posting the daily nurse staffing information for the day and evening shift, while the nursing supervisor posted the night shift and weekend staffing when they were not working. The Nursing Scheduler stated they thought the staffing had been posted on 04/14/2026 but could not recall, and they were not aware that the daily census or actual hours worked were required.
Failure to Provide Required Medicare Non-Coverage and Liability Notices
Penalty
Summary
The facility did not provide the required Medicare liability and appeal notices to a Medicare beneficiary when Medicare Part A coverage ended. Resident #93, who had diagnoses including stroke with right-sided paralysis and weakness and had intact cognition, had a Skilled Nursing Facility Part A discharge assessment showing a Medicare-covered stay from 10/01/2025 through 12/13/2025. The record contained no documented evidence that CMS Form 10055 or CMS Form 10123 were provided to the resident when Medicare benefits ended. During interview, the Rehabilitation Director stated they were responsible for providing CMS Form 10123 and the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS Form 10055), but they had assumed this responsibility after the Minimum Data [NAME] Coordinator left and had not received training for the task. The Rehabilitation Director stated CMS Form 10055 was not provided to Resident #93, and although CMS Form 10123 was provided, the facility could not locate a copy because many of these forms were lost due to a prior system process. The Administrator stated they were aware the facility had a problem locating CMS Form 10123 and CMS Form 10055 provided to residents and acknowledged this was a deficient practice.
Failure to Administer and Document IV Antibiotics as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including osteomyelitis of the thoracic vertebrae, local skin infection, and sepsis did not receive several prescribed intravenous antibiotic doses. Physician orders required administration of cefepime and vancomycin every 12 hours, but the Medication Administration Record (MAR) showed blank entries for multiple scheduled doses, indicating they were either not given or not documented. There was no evidence in the nursing progress notes of missed doses or provider notification regarding these omissions. Interviews with nursing staff revealed confusion and inconsistency regarding responsibility for intravenous medication administration and documentation. LPNs and RNs described different processes for being alerted to medication times, and some staff were unsure why MAR entries were left blank. Supervisory staff acknowledged that a blank MAR box meant the medication was unaccounted for, and that this constituted a medication error. However, there was no documentation of any investigation into the missing administrations, nor was there evidence that the provider was notified as required by facility policy. The physician responsible for the resident's care confirmed that they were not notified of any missed antibiotic doses, which they considered a significant medication error. Facility leadership, including the DON and Assistant DON, stated that all MAR entries should be completed and that missed or undocumented doses should be investigated and reported. Despite this, no such actions were documented, and the missed doses remained unaccounted for.
Failure to Obtain Timely and Accurate Vancomycin Trough Levels
Penalty
Summary
The facility failed to ensure timely and accurate laboratory services for one resident who was receiving intravenous vancomycin for osteomyelitis, discitis, and sepsis. Physician orders required regular monitoring of vancomycin trough levels and other laboratory tests to assess the effectiveness and safety of the antibiotic therapy. Despite these orders, there was no documented evidence that the required vancomycin trough levels were obtained on the specified dates, and the only recorded trough was not performed at the appropriate time relative to the dosing schedule. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that laboratory draws were scheduled on specific days of the week, and there was confusion or lack of clarity regarding the timing of the vancomycin trough draws. The registered nurses were responsible for drawing blood from the resident's peripherally inserted central catheter, but the records did not show that the required labs were completed as ordered. The pharmacy and consultant pharmacist were not contacted with the necessary lab results, and the facility failed to communicate effectively regarding the resident's laboratory needs. The failure to obtain timely and accurate vancomycin trough levels was confirmed through record review and staff interviews. The physician stated that the trough levels should have been drawn every three days and prior to the next scheduled dose, and that delays or missed draws were not acceptable. The lack of appropriate laboratory monitoring was not explained by the staff, and there was no documentation to support that the required tests were performed as ordered.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure that Resident #2 received medications as ordered, leading to a deficiency in providing treatment and care according to professional standards and the resident's care plan. Resident #2, who had diagnoses including depression, diabetes, chronic obstructive pulmonary disease, and Parkinson's Disease, did not receive several critical medications on multiple occasions. These medications included Rytary for Parkinson's, Novolog for diabetes, Pulmicort for respiratory issues, and vilazodone for depression. The absence of these medications was documented by various Licensed Practical Nurses over several days, with no evidence that a provider was notified about the unavailability of these medications. The facility's policy required that any medication not administered should be documented, and the medical professional should be informed to obtain further orders. However, this protocol was not followed, as there was no documented evidence that the provider was notified about the missing medications. The facility's practice of requiring corporate approval for medications over $50 contributed to delays in medication availability. This process led to significant delays in obtaining necessary medications for Resident #2, who experienced worsening symptoms, including dysarthria and chest pain, potentially related to the missed medications. Interviews with facility staff, including Licensed Practical Nurses, the Corporate Pharmacy Liaison, and the Director of Nursing, revealed systemic issues in medication management and communication. Staff reported that medications were often unavailable for extended periods, and there was confusion about the process for obtaining medications from the Cubex or notifying providers. The Medical Director emphasized the importance of timely medication administration, particularly for conditions like Parkinson's Disease, where missing doses can lead to symptom recurrence. The deficiency highlights a failure in the facility's medication management system, impacting the resident's health and well-being.
Deficiency in Grievance Process and Resident Rights
Penalty
Summary
The facility failed to ensure a proper grievance process was in place for residents, as evidenced by the lack of awareness among residents about the grievance officer and the handling of grievances. During a Resident Council Meeting, twelve anonymous residents expressed that they were unaware of who the grievance officer was and did not receive follow-up on their grievances. Additionally, the facility did not have visible postings of the grievance officer's contact information, which is a requirement according to their policy. Resident #16, who has cerebral palsy, anxiety disorder, and depression, reported feeling uncomfortable with the behavior of two Certified Nurse Aides (CNAs) during care. The resident filed a grievance about the CNAs being inappropriately touchy with each other and not assisting with unlocking the door for visitors. The grievance was documented, but the resolution was incomplete, as only one CNA received re-education, and the resident's request to not be cared for by the involved CNAs was not fully addressed. Interviews with facility staff revealed inconsistencies in the grievance handling process. The Social Worker and Registered Nurse Unit Manager acknowledged the resident's dissatisfaction and the incomplete resolution of the grievance. The Director of Nursing and the Administrator confirmed that grievances should be resolved within 72 hours and that residents have the right to refuse care from certain staff members. However, there was a lack of documentation and follow-through in addressing Resident #16's concerns, highlighting a deficiency in the facility's grievance process.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, it was observed that hot food was improperly cooled, the mechanical dishwasher was not functioning as designed, and outdated foods were present in the walk-in cooler. Specifically, a pan of rice was found in the walk-in cooler at a temperature of 123 degrees Fahrenheit, which did not meet the required cooling standards. The rice was not properly monitored for temperature reduction, and similar issues were noted with other food items like turkey and pork loin, which had incomplete cooling records. The mechanical dishwasher was also found to be malfunctioning, with wash temperatures recorded below the required 150 degrees Fahrenheit and final rinse temperatures below the necessary 180 degrees Fahrenheit. The chlorine sanitizer levels were also inconsistent, with measurements as low as 10 parts per million, far below the required levels. The Maintenance Director confirmed that the dishwasher had been operating with a broken heating element for an extended period, and the facility had been using chemical sanitization as a workaround. Additionally, outdated food items were found in the walk-in cooler, including a pan of chicken labeled from 7/11 and a bag of cooked potatoes dated 7/3. Staff interviews revealed a lack of a specific person responsible for reviewing cooler contents, leading to the presence of outdated items. The Temporary Food Service Director acknowledged that these items should not have been in the cooler, indicating a lapse in monitoring and adherence to food safety protocols.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. On Unit 1, medication cart 1 contained several medications, including multidose insulin pens, eye drops, and ointments, that were not labeled with resident-specific identifiers or opened/discard dates. Additionally, an unopened insulin pen was not stored in the refrigerator as required. Licensed Practical Nurse #18 admitted to administering an undated insulin pen to a resident without checking for an opened date, which is necessary to determine expiration. On Unit 2, medication cart 1 had a multidose insulin pen without resident-specific information or an opened/discard date, and another insulin pen for a specific resident also lacked an opened/discard date. Medication cart 2 contained expired stock medications. Licensed Practical Nurse #1 acknowledged that they would not use medications without knowing the intended resident or expiration status. The Assistant Director of Nursing had previously checked the carts for expired medications, but these issues were not identified. Interviews with nursing staff revealed a lack of knowledge regarding the duration insulin is viable after opening and the absence of documentation for weekly expiration checks. The Assistant Director of Nursing stated that night shift nurses were responsible for checking expiration dates weekly, but it was unclear if these checks were documented. The facility lacked an educator, and staff were unsure when they last received education on medication storage, contributing to the oversight of expired and improperly labeled medications.
Inadequate Infection Control Practices for Resident on Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to transmission-based precautions for a resident diagnosed with clostridium difficile. The facility's policy required staff to wear gloves and gowns when entering the room of a resident on contact precautions, and to perform hand hygiene before leaving the room. However, observations revealed that staff members, including a Certified Nurse Aide, a Registered Nurse Unit Manager, and a Licensed Practical Nurse, did not consistently follow these protocols. Resident #59, who had a history of recurrent enterocolitis due to clostridium difficile, was placed on contact precautions upon readmission to the facility. Despite the presence of signage indicating the need for contact precautions, staff were observed entering and exiting the resident's room without the required personal protective equipment. Additionally, staff failed to perform hand hygiene after leaving the room, and contaminated items were handled inappropriately, increasing the risk of infection transmission. Interviews with staff members revealed a lack of understanding and adherence to the facility's infection control protocols. The Registered Nurse Unit Manager acknowledged the need for gowns and gloves when entering the resident's room and admitted to not following proper procedures. The Director of Nursing/Infection Preventionist confirmed that staff were expected to follow the signage and that there was no appropriate time to enter an isolation room without the required protective equipment. This deficiency highlights a significant lapse in the facility's infection control practices, particularly in protecting residents and staff from communicable diseases.
Failure to Notify Resident's Representative of Antibiotic Treatment
Penalty
Summary
The facility failed to immediately inform the resident's representative about the initiation of a new treatment for a resident, which is a requirement according to their policy. Specifically, a resident with a history of stroke, sacral pressure ulcer, and infections was prescribed antibiotics due to an elevated white blood cell count indicating an infection. Despite the facility's policy mandating notification within 24 hours of a change in the resident's medical condition, the resident's representative was not informed about the antibiotic treatment. The resident's medical records showed that antibiotics, Doxycycline and Ceftriaxone, were prescribed on consecutive days to address the infection. However, progress notes by the registered nurse did not document any signs or symptoms of infection, the use of antibiotics, or the notification of the resident's representative. Interviews with the resident's representative and the Director of Nursing confirmed that the family was not notified about the antibiotic therapy, which was acknowledged as a lapse in procedure.
Failure to Provide Necessary Equipment for Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of Resident #3. The resident, who had diagnoses including left-sided hemiplegia, unspecified visual loss, and depression, was not provided with a large print Bible or glasses, which were necessary for their participation in activities. The resident's care plan indicated a preference for independent activities and 1:1 visits, and it was documented that they required visual aids to participate in activities. However, during the survey, it was found that the resident's glasses were missing, and they did not have access to a large print Bible, which was part of their documented interests. Interviews with facility staff revealed a lack of awareness regarding the resident's missing glasses and Bible. The Activities Director and Activity Aide were responsible for ensuring residents' interests were met, but they were not aware of the resident's needs for glasses and a large print Bible. The Activities Director acknowledged that the resident's care plan documented these needs, but the resident did not have glasses in their room, and the Bible provided was not large print. The facility's failure to ensure the resident had the necessary equipment and supplies for their preferred activities led to the deficiency.
Failure to Ensure Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, two residents with pressure ulcers did not have their low air loss mattresses set according to their current weights, and the settings were not documented in their care plans or physician orders. This oversight was observed during a recertification survey, where it was found that the mattresses were not monitored to ensure appropriate settings for the residents' weights. Resident #27, who had a Stage 4 pressure ulcer, diabetes, and morbid obesity, was found to have their low air loss mattress set on static at 325 pounds, despite weighing 211 pounds. The mattress settings were not documented in the physician orders or care plan, and the Treatment Administration Record indicated that checks were not consistently performed every shift. Observations revealed that the resident experienced pain from the pressure ulcer, and the mattress settings were not adjusted to provide optimal pressure relief. Resident #67, who had a history of surgery and an intellectual disability, was at risk for impaired skin integrity and had an unstageable pressure ulcer on the left buttock. The resident's low air loss mattress was set on alternating at 250 pounds, but the settings were not documented in the care plan or physician orders. Interviews with staff revealed a lack of clarity regarding who was responsible for setting and monitoring the mattresses, leading to inconsistencies in ensuring the mattresses were set according to the residents' weights.
Failure to Supervise Resident with Dysphagia During Meals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with dysphagia, a condition that makes swallowing difficult. The resident was care planned for line-of-sight supervision during meals, with specific strategies to ensure safe swallowing, such as consuming small, single bites and maintaining an upright position during and after meals. Despite these requirements, the resident was observed eating alone in their room without any staff supervision, which was contrary to the care plan and facility policies. The facility's policies on meal observation and assistance with meals required staff to supervise residents during mealtime, especially those on altered diets, to ensure safety and meet individual needs. The resident in question had a comprehensive care plan that included supervision during meals due to their limited mobility and risk of swallowing difficulties. However, during an observation, the resident was found eating lunch alone, with their back to the door, and no staff present to provide the necessary supervision. Interviews with facility staff, including a CNA, RN Unit Manager, and Speech and Language Pathologist, confirmed that the resident should have been supervised during meals. The staff acknowledged that residents on altered diets, like the one in question, were at risk for aspiration or choking and required supervision. The RN Unit Manager and Speech and Language Pathologist both stated that the resident should have been either in the dining room or accompanied by a staff member while eating in their room, highlighting a lapse in following the care plan and facility protocols.
Inadequate Respiratory Care for Resident Using BiPAP
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #19, who required the use of a bilevel positive airway pressure (BiPAP) machine. The facility's policy required the BiPAP machine to be cleaned weekly and the mask, nasal pillow, and tubing to be cleaned daily. However, there was no documentation of a cleaning schedule for the device, and the comprehensive care plan did not include maintenance or cleaning instructions for the BiPAP equipment. Observations revealed that the resident's BiPAP mask was found on the floor and had visible white and black specks inside, indicating it was not cleaned regularly. The mask harness was frayed, and surgical tape was used to secure the tubing, suggesting inadequate maintenance. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse Manager, confirmed that there were no physician orders for cleaning the equipment, and the task was not consistently documented in the treatment administration record. The Director of Nursing and a physician acknowledged the lack of proper orders and documentation for cleaning and changing the BiPAP equipment. They noted that the resident had experienced respiratory infections, which could have been linked to the unclean equipment. The facility's failure to adhere to professional standards of practice for respiratory care resulted in a deficiency, as the resident's equipment was not maintained or cleaned as required, potentially compromising the resident's health.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis services received care consistent with professional standards. Resident #59, who had end-stage renal disease and required hemodialysis, did not receive ongoing assessments and oversight before and after dialysis treatments. The facility's policy required pre-dialysis evaluations, including vital signs and access site assessments, to be documented in a communication book and the resident's medical chart. However, there was no documented evidence of these evaluations being completed for the resident during the specified period. The resident's communication book, which was supposed to facilitate information exchange between the facility and the dialysis center, was incomplete and outdated. It lacked current medication lists and recent evaluations, and there was no documentation of pre-dialysis or post-dialysis evaluations for several dates. Interviews with facility staff revealed a lack of clarity and responsibility regarding the documentation and communication process, leading to incomplete records and potential gaps in care. The facility's failure to document and communicate essential information about the resident's dialysis treatments and access site assessments compromised the resident's safety. Staff interviews highlighted the importance of monitoring vital signs and the dialysis access site for signs of infection or complications, yet these evaluations were not consistently documented. The lack of proper documentation and communication between the facility and the dialysis center raised concerns about the resident's care and the facility's adherence to professional standards.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, flavorful, and served at appetizing temperatures. During the recertification survey, it was observed that meals served on two separate occasions were not at the appropriate temperatures and lacked flavor. Specifically, the lunch meals on 7/16/2024 and 7/18/2024 were served at temperatures below the required standards, with hot foods not being hot enough and cold foods not being cold enough. Additionally, the meals were described as bland and unappetizing by residents and staff. The survey also revealed that the facility's meal service was inconsistent and inaccurate. During a Resident Council meeting, 12 anonymous residents reported that their meals often had missing items and were not served at the correct temperatures. A test tray on 7/18/2024 contained a foreign substance, identified as parchment paper, which was mixed with the food, posing a potential choking hazard. The facility's policies on dining experience and tray line service were not adhered to, as meals were not checked for accuracy and quality before being served. Interviews with staff highlighted issues with menu changes and communication. The Acting Food Service Director and Dietary Supervisor acknowledged that the menu was changed without proper updates to meal tickets, leading to missing items like apple slices. The Registered Dietitian was unaware of the availability of certain foods and did not conduct test trays to ensure meal quality. The facility's failure to maintain proper food temperatures and ensure meal accuracy resulted in a deficiency in providing a satisfactory dining experience for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 109 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand Rehabilitation And Nursing At Rome | 0.9 mi | ★★★★★ | 29 | 1 |
| Rome Memorial Hospital, Inc - R H C F | 1 mi | ★★★★★ | 0 | 0 |
| Bethany Gardens Skilled Living Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Betsy Ross Rehabilitation Center, Inc | 2 mi | ★★★★★ | 2 | 0 |
| Trustees Of Eastern Star Hall & Home Of The N Y S | 6.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.