Colonial Park Rehabilitation and Nursing Center

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure a process was in place for residents to have their grievances addressed appropriately for 79 of 79 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Additionally, six (6) of six (6) anonymous residents present at the resident group meeting stated they did not know if there were grievance forms or where they would be located, of their right to file anonymously, did not know who the grievance officer was, and resident council concerns were not addressed.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intakes 2807999 and 473681) the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (2) of six (6) residents (Residents #7 and #64) reviewed. Specifically, Resident #7 had significant weight loss, weights were not obtained as ordered, and there was no documented evidence a medical provider addressed the resident's weight loss; Resident #64 did not receive their nutritional supplements as ordered, had a decline in their eating abilities, and was not assisted at meals.

Inspectors wroteBased on observations and interviews (iQIES intake 2963932), the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional needs for six (6) anonymous residents and two (2) of two (2) meals (the 04/15/2026 and 04/16/2026 lunch meals) reviewed. Specifically, the 04/15/2026 lunch meal had hot and cold food served outside of the appropriate temperature range; the 04/16/2026 lunch meal tray had missing food items, missing adaptive meal equipment, and food items were not serviced at palatable temperatures and the 04/16/2026 replacement lunch meal was missing items, the appropriate adaptive equipment was not provided, and the meal ticket directions were not followed; and six (6) anonymous residents present at the resident group meeting stated the food was often cold and the meal tray did not match the meal tickets.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to consult with the physician when there was a significant change in the resident's physical status for one (1) of one (1) resident (Resident #3) reviewed. Specifically, Resident #3 had significant weight gain, weights were not obtained as ordered, there was no documented evidence that the physician was notified of a significant weight gain, and the resident was hospitalized .

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure services provided met professional standards of clinical practice for one (1) of four (4) residents (Resident #7) reviewed. Specifically, Resident #7 regularly refused their ordered inhaler and nebulizer treatments (respiratory treatments) and there was no documented evidence the physician was notified of the refusals or reviewed the resident's medication administration records during their monthly visits; there was no documented evidence the irregularity of the refused medications were noted by the pharmacist during their monthly medication reviews; and there was no documented evidence of a care plan related to the resident's refusals of their medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #85) reviewed. Specifically, Resident #85 was admitted to the facility, was not assessed by a registered nurse until three (3) days later on the day they were discharged against medical advice; physician orders were not completed; treatments were not provided as ordered; diagnostic testing was not completed as ordered; and care was not provided for two (2) of nine (9) shifts during the residents admission. Additionally, when the resident was discharged against medical advice there was no documented evidence of who the resident left with, if education was provided to the resident, and if a medical provider was notified.

Inspectors wroteBased on observations, record review, and interviews (IQIES Intake 2577870), the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for one (1) of three (3) residents (Resident #64) reviewed. Specifically, Resident #64's wound treatments were not completed as ordered.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #52) reviewed. Specifically, Resident #52's tube feeding was not infusing at the ordered rate; they did not receive their water flushes as ordered; their tube feeding was not dated: and their tube feeding pump was unclean with brownish streaks on the monitor.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure that residents who required dialysis (used to filter waste products from the blood when the kidneys do not work properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #4) reviewed. Specifically, Resident #4 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of one (1) resident (Resident #49) reviewed. Specifically, Resident #49 exhibited behavioral disturbances, did not have a personalized care plan to address triggers or personalized interventions, and the facility did not coordinate with outside behavioral health services for continuity of care.

Inspectors wroteBased on observations and interviews the facility failed to ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them. Specifically, the facility did not provide records for the standard health survey results or any complaint survey results and subsequently, there was no posted notification of the availability of the previous three (3) years of survey reports.

Inspectors wroteBased on observations and interviews, the facility failed to ensure nurse staffing information was posted daily at the beginning of each shift and included the daily current resident census and the total number, and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent location readily accessible to residents and visitors for four (4) of four (4) days (04/14/2026, 04/15/2026, 04/16/2026, and 04/17/2026) reviewed. Specifically, the facility did not post the daily nurse staffing on 04/14/2026 and the posted daily nurse staffing on 04/15/2026, 04/16/2026, and 04/17/2026 did not include the resident census and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care as required.

Inspectors wroteBased on record review and interviews the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for one (1) of three (3) residents (Resident #93) reviewed. Specifically, Resident #93 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending, nor a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A, as required.

Inspectors wroteBased on record review and interviews during the abbreviated (iQIES reference number 2610929) survey the facility did not ensure residents were free of significant medication errors for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order for intravenous (directly into a vein) cefepime and vancomycin (antibiotics) every 12 hours that were not administered on 04/10/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/18/2025, and 04/19/2025.

Inspectors wroteBased on record review and interviews during the abbreviated (iQIES reference number 2610929) survey the facility did not ensure laboratory services were obtained to meet the needs of its residents for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had physician orders for laboratory tests to check their vancomycin (antibiotic) trough level (blood test used to monitor the antibiotic's effectiveness and to minimize toxicity) and the laboratory tests were not performed timely or accurately.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00334012), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive medications as ordered on multiple occasions.

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00340720) surveys conducted 7/15/2024-7/22/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 13 of 13 (12 anonymous residents, and Resident #16) reviewed. Specifically, 12 anonymous residents present at the Resident Council meeting stated they did not know who the grievance officer was, how grievances were handled, or receive communication on the progress of grievance resolutions; and Resident #16 filed a grievance regarding a care concern that was not resolved.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, hot food was improperly cooled, the mechanical dishwasher was not functioning as designed, and outdated foods were present in the walk-in cooler.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 3 medication carts (Unit 1- medication cart 1, Unit 2- medication cart 1, and Unit 2- medication cart 2) reviewed. Specifically, - Unit 1- medication cart 1 contained 7 medications that were not labeled with resident specific identifiers or with opened/ discard dates; 7 resident specific multidose insulin (treats blood sugar) pens, 1 multidose eye drop, and 1 multidose eye ointment that were not labeled with opened and discard dates; and 1 unopened insulin pen that was not stored appropriately in the refrigerator. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #59) reviewed. Specifically, staff was observed not wearing the required personal protective equipment in Resident #59's room who was on transmission-based precautions.

Inspectors wroteBased on record review and interview during the recertification and abbreviated (NY00340720) surveys conducted 7/15/2024-7/22/2024, the facility did not immediately inform the resident's representative when there was a need to commence a new treatment for 1 of 2 residents reviewed (Resident #525). Specifically, Resident #525 was prescribed an antibiotic for symptoms of infection and the resident's representative was not notified.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #3) reviewed. Specifically, Resident #3 was not provided a large print Bible or glasses to meet their interests and preferences.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 3 residents (Residents # 27and #67) reviewed. Specifically, Residents #27 and #67 had physician orders for air low air loss mattresses (a specialty mattress that provides air flow to relieve pressure) that did not include settings and were not monitored to ensure appropriate settings for current weights.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00314958) surveys conducted 7/15/2024-7/22/2024, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #7) reviewed. Specifically, Resident #7 had a diagnosis of dysphagia (difficulty swallowing) and was care planned for line-of-sight supervision for meals with specific swallowing strategies and was observed eating a meal alone in their room.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 1 resident reviewed (Resident #19). Specifically, Resident #19's bilevel positive airway pressure machine (non-invasive mechanical ventilator that applies pressure to keep airway open when sleeping) was not cleaned per professional standards.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure that residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #59) reviewed. Specifically, Resident #59 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site. Additionally, there was not consistent ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on observation and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 test tray meals (the 7/16/2024 lunch meal and the 7/18/2024 lunch meal) reviewed; and for 12 of 12 anonymous residents present at the Resident Council meeting. Specifically, the 7/16/2024 and 7/18/2024 lunch meals were not served at palatable and appetizing temperatures and were not flavorful; the 7/18/2024 lunch meal test tray contained a foreign substance and had a missing item. Additionally, 12 of 12 anonymous residents at the Resident Council meeting stated the food was not flavorful, was not served at appetizing and palatable temperatures, and often had missing items; [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00321800), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, Resident #3, who was previously diagnosed with brain cancer, had recommendations for a magnetic resonance imaging scan (specialized x-ray) and follow-up with oncology (cancer specialist) and neurology (doctor who specializes in diseases of the brain/spinal cord), and there was no documented evidence the follow-up appointment or scan was scheduled or occurred. Subsequently, the resident experienced a decline in their neurological function. This resulted in actual harm to Resident #3 that was not immediate jeopardy.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00312863), the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a significant weight loss that was not addressed by clinical nutrition staff. Additionally, the resident was not consistently provided with their ordered nutritional supplement.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00258908, NY00291516, NY00276440, NY00296424, NY00286768, and NY00285103) conducted 5/31/22-6/3/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 2 resident units (A and B units) reviewed. Specifically, there were loose and unclean handrails, unclean floors, and walls and furniture in disrepair on the A (100s) and B (200s) units.

Inspectors wroteBased on observation, record review, and interview during the abbreviated (NY00290033) and recertification surveys conducted from 5/31/22-6/3/22, the facility failed to protect residents from abuse for 2 of 3 residents reviewed (Residents #26 and 47). Specifically, Resident #4 exhibited sexually inappropriate behaviors towards Residents #26 and 47 and a plan of care was not developed and implemented to protect Residents #26 and 47 from further abuse.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00286768 and NY00296424) conducted 5/31/22-6/3/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 of 2 meal test trays, and for 1 meal service in the kitchen. Specifically, 2 lunch meal test trays and several food items on the kitchen lunch service line had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable.

Inspectors wroteBased on interview and record review during the recertification and abbreviated surveys (NY00296424) conducted from 5/31/22-6/3/22, the facility failed to ensure that the discharge needs of each resident were identified and resulted in the development of a discharge plan for each resident for 1 of 1 resident (Resident #174) reviewed. Specifically, Resident #174 was discharged to home following a rehabilitation admission and did not have home care services set up at the time of discharge.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00258908, NY00265830, NY00291516, NY00274357, NY00264477) conducted 5/31/22-6/3/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents reviewed (Resident # 24). Specifically, Resident # 24 was not provided timely incontinence care as planned.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted on 5/31/22-6/3/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Residents #32 and 38) reviewed. Specifically, Residents #32 and 38, both on aspiration precautions, were unsupervised and not positioned safely during meals. Additionally, Resident #32 was not provided the correct diet consistency during an observed lunch meal.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 5/31/22-6/3/22, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for 1 of 2 (A-1 medication cart) medication carts reviewed. Specifically, controlled drugs were not stored in the separately locked compartment in the A-1 medication cart.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00286768 and NY296424) conducted 5/31/22-6/3/22, the facility failed to ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 of 1 resident (Residents #17) reviewed. Specifically, Resident #17 had a gluten allergy (a protein found in grains), and the resident was served mashed potatoes instead of gluten free pasta listed on the approved menu.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 5/31/22-6/3/22, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19 for 1 of 11 staff (licensed practical nurse [LPN] #10) reviewed. Specifically, the facility did not implement their contingency plan for LPN #10 who was not vaccinated for COVID-19 due to an exemption based on clinical contraindications.