Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
188% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse and safety concerns at Colonial Rehabilitation and Nursing, LLC.
Complaint Details
The complaint investigation substantiated that Resident #15 verbally abused Resident #5 on 10/1/25, including threatening behavior and attempted physical aggression. The facility investigation also found that on 10/17/25, Resident #7 was injured due to improper use of a manual Hoyer lift which tipped during transfer, causing the resident to fall but without injury.
Findings
The facility substantiated verbal abuse by Resident #15 towards Resident #5 and identified issues with the safe use of mechanical lifts leading to a resident fall. The facility also failed to ensure an environment free from accident hazards and adequate supervision to prevent accidents.
Deficiencies (2)
Failed to protect Resident #5 from verbal abuse by Resident #15.
Failed to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically related to the use of mechanical lifts with Resident #7.
Report Facts
Residents reviewed for abuse: 8
Residents affected by abuse deficiency: 1
Residents reviewed for accident hazards: 3
Residents affected by accident hazard deficiency: 1
Staff competencies assessed: 16
Date of abuse incident: Oct 1, 2025
Date of lift incident: Oct 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided facility investigation and was primary de-escalator for Resident #15. |
| Assistant Director of Nursing | ADON | Intervened during Resident #15's aggressive incident and involved in lift incident investigation. |
| Director of Nursing | DON | Interviewed regarding Resident #15's behaviors and lift incident; involved in staff education. |
| Certified Nurse Aide #1 | CNA | Interviewed about staffing and Resident #15's behaviors. |
| Certified Nurse Aide #2 | CNA | Interviewed about Resident #15's behaviors and lift use. |
| Certified Nurse Aide #3 | CNA | Observed assisting with Resident #7's transfer using manual Hoyer lift. |
| Certified Nurse Aide #4 | CNA | Observed assisting with Resident #7's transfer and interviewed about lift use. |
| Registered Nurse #1 | RN | Interviewed about Resident #15's behaviors and lift use. |
Inspection Report
Routine
Census: 39
Deficiencies: 14
Date: Jul 24, 2025
Visit Reason
Routine inspection of Colonial Rehabilitation and Nursing, LLC to assess compliance with regulatory standards including resident care, medication management, infection control, and safety.
Findings
The inspection identified multiple deficiencies including failure to protect residents from abuse, inadequate psychotropic medication management, failure to provide preferred communication devices, insufficient activity programming, inadequate wound care and pressure ulcer prevention, failure to implement effective fall prevention interventions, improper catheter care, failure to monitor feeding tube placement, inadequate dementia care interventions, and lapses in infection control practices.
Deficiencies (14)
Failure to protect residents from physical abuse by another resident, with substantiated incidents involving multiple residents.
Failure to ensure psychotropic medications were used with least restrictive approaches and proper documentation for residents.
Failure to provide Resident #49 with preferred communication devices during activities of daily living.
Failure to provide personalized activity programs and ensure participation for residents with dementia and cognitive impairments.
Failure to implement effective wound care and offloading interventions for Resident #18's ankle wound.
Failure to reposition Resident #14 to prevent pressure ulcer worsening and inconsistent implementation of pressure injury care plan.
Failure to apply hand splint as ordered for Resident #18 to maintain limb function and mobility.
Failure to implement timely, person-centered fall prevention interventions for Resident #4 after multiple falls including a hip fracture.
Failure to provide adequate supervision and fall prevention interventions for Resident #4, a high fall risk resident.
Failure to provide appropriate catheter care for Resident #7 including use of privacy bag, proper catheter placement, timely emptying of catheter bag, and consistent monitoring of intake and output.
Failure to ensure feeding tube placement was verified prior to bolus feeding administration for Resident #22.
Failure to develop and implement effective dementia management interventions to prevent wandering and unsafe behaviors for Resident #47.
Failure to ensure catheter care staff followed enhanced barrier precautions including use of gloves and gowns when emptying catheter bags for Resident #7.
Failure to monitor hours of sleep for residents on insomnia medications for Residents #61 and #42.
Report Facts
Residents affected: 39
Falls: 12
BIMS score: 4
BIMS score: 2
BIMS score: 13
BIMS score: 5
Wound measurements: 2.5
Wound measurements: 1
Wound measurements: 0.1
Medication doses: 3
Medication doses: 1
Medication doses: 25
Medication doses: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Interviewed regarding abuse incidents and behavior monitoring |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding abuse incidents and behavior monitoring |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse, medication monitoring, wound care, falls, catheter care, and dementia management |
| RCR | Regional Clinical Resource | Provided facility policies and interviewed regarding deficiencies |
| NHA | Nursing Home Administrator | Interviewed regarding activity programming and fall prevention |
| AA #1 | Activity Assistant | Observed and interviewed regarding activity programming |
| PTA #1 | Physical Therapy Assistant | Interviewed regarding wound care and therapy for Resident #18 |
| OT #1 | Occupational Therapist | Interviewed regarding hand splint use for Resident #18 |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding catheter care and feeding tube administration |
| CNA #3 | Certified Nurse Aide | Observed and interviewed regarding catheter care and infection control |
| IP | Infection Preventionist | Interviewed regarding infection control practices |
Inspection Report
Routine
Deficiencies: 13
Date: Jul 24, 2025
Visit Reason
Routine state inspection survey of Colonial Rehabilitation and Nursing, LLC to assess compliance with regulatory requirements including resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to protect residents from abuse, improper use and monitoring of psychotropic medications, inadequate assistance with activities of daily living and communication, insufficient activity programming, failure to provide appropriate wound and pressure ulcer care, inadequate fall prevention interventions, improper catheter care, failure to ensure proper use of splints for mobility, inadequate supervision to prevent accidents, failure to monitor sleep for residents on insomnia medications, and lapses in infection control practices.
Deficiencies (13)
F0600: The facility failed to protect four residents from physical abuse by another resident, despite prior incidents and interventions.
F0605: The facility failed to ensure three residents were free from unnecessary psychotropic medications and lacked documentation of non-pharmacological interventions and gradual dose reductions.
F0677: The facility failed to provide Resident #49 with her preferred communication device during activities of daily living.
F0679: The facility failed to provide personalized activity programs and failed to redirect residents exhibiting wandering and exit-seeking behaviors.
F0684: The facility failed to provide appropriate treatment and care for Resident #18, including inconsistent use of a boot for wound offloading and failure to prevent recurring wounds.
F0686: The facility failed to provide consistent turning and repositioning for Resident #14 with a stage three pressure ulcer, resulting in prolonged pressure on the wound area.
F0688: The facility failed to ensure Resident #18's hand splint was applied as ordered to maintain limb function and mobility.
F0689: The facility failed to implement timely person-centered fall interventions for Resident #4 after multiple falls and a major injury.
F0690: The facility failed to provide appropriate catheter care for Resident #7, including failure to use gloves and gown when emptying catheter bag, improper catheter placement, and inconsistent monitoring of intake and output.
F0693: The facility failed to ensure Resident #22's feeding tube was checked for proper placement prior to administering bolus feedings.
F0744: The facility failed to develop and implement effective dementia management interventions to prevent Resident #47 from wandering into other residents' rooms and standing over other residents.
F0757: The facility failed to ensure drug regimens were free from unnecessary medications and failed to monitor hours of sleep for residents on insomnia medications.
F0880: The facility failed to maintain an infection control program by not following proper infection control procedures for Resident #7 on enhanced barrier precautions.
Report Facts
Falls: 12
BIMS score: 4
BIMS score: 2
BIMS score: 13
BIMS score: 5
BIMS score: 9
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Interviewed regarding feeding tube care and splint application for Resident #22 and Resident #18. |
| CNA #3 | Certified Nurse Aide | Observed emptying catheter bag without gloves or gown for Resident #7. |
| DON | Director of Nursing | Interviewed regarding multiple care deficiencies including fall prevention, medication monitoring, catheter care, and infection control. |
| RCR | Regional Clinical Resource | Provided facility policies and interviewed regarding medication and care standards. |
| Wound Care Physician | Physician | Provided wound care orders and interviewed regarding Resident #18's wound. |
| OT #1 | Occupational Therapist | Interviewed regarding Resident #18's hand splint and therapy. |
| AD | Activity Director | Interviewed regarding activity programming and Resident #17 and #36 participation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure residents had the right to choose their preferred attending physician after a change in medical provider groups.
Complaint Details
The complaint investigation found that four of six sampled residents were not properly informed or assisted in selecting their attending physician following a change in medical provider groups. Residents reported lack of informed consent and knowledge of insurance coverage. The facility was unable to provide documentation of informed consent from residents or their legal representatives.
Findings
The facility failed to assist four of six sampled residents in making an informed choice of attending physician when the facility changed medical provider groups. Documentation showed undated and unsigned provider choice forms completed by staff without resident or legal representative signatures, and residents reported not being informed of their rights or insurance coverage related to physician choice.
Deficiencies (1)
Failure to ensure residents had the right to choose their preferred attending physician after a change in medical provider groups.
Report Facts
Residents affected: 4
Sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding facility ownership change and medical provider contracts |
| Social Services Director | SSD | Completed provider choice forms and assisted residents in selecting attending physicians |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Aug 31, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident-to-resident abuse, inadequate supervision to prevent accidents, hydration issues, medication errors, nutritional deficiencies, therapeutic diet noncompliance, food palatability, and food safety practices.
Complaint Details
The complaint investigation substantiated resident-to-resident abuse involving Residents #48 and #52. Additional complaints included inadequate supervision leading to falls, hydration deficiencies, medication errors, failure to follow therapeutic diets, and food safety concerns.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident physical abuse, inadequate supervision leading to falls and injuries, failure to ensure adequate hydration for residents, significant medication administration errors, failure to follow prescribed therapeutic diets, serving food that was not palatable or served at appropriate temperatures, and failure to properly label and date food items in the kitchen.
Deficiencies (8)
Failed to ensure residents were free from resident-to-resident physical abuse between Resident #48 and Resident #52.
Failed to ensure adequate supervision to prevent accidents for Resident #40 who experienced two falls, one resulting in a right hip fracture.
Failed to provide sufficient hydration to Residents #21 and #25 according to their care plans.
Failed to prevent significant medication errors for Residents #41 and #49, including failure to administer prescribed medications as ordered.
Failed to follow menus to meet residents' nutritional needs, including incorrect portion sizes and serving incorrect items.
Failed to serve food that was palatable, attractive, and at appropriate temperature; residents reported cold meals, tough meat, and unappetizing food.
Failed to provide therapeutic carbohydrate controlled diets (CCD) as prescribed to Residents #69 and #67.
Failed to ensure food items removed from original packaging were properly labeled and dated to prevent contamination and food-borne illness.
Report Facts
Residents reviewed for physical abuse: 32
Residents reviewed for falls supervision: 32
Residents reviewed for hydration: 5
Residents reviewed for medication errors: 32
Residents reviewed for therapeutic diet: 16
Fluid needs for Resident #10: 1475
Fluid needs for Resident #10: 1770
Fluid needs for Resident #21: 1925
Fluid needs for Resident #21: 2310
Fluid intake average for Resident #21: 550
Medication refusal dates for Resident #41: 15
Residents affected by therapeutic diet noncompliance: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered nurse #1 | RN | Interviewed regarding supervision and abuse incident |
| Director of Nursing | DON | Interviewed regarding supervision, medication errors, and dietary compliance |
| Certified nurse aide #1 | CNA | Interviewed regarding hydration and resident assistance |
| Certified nurse aide #2 | CNA | Interviewed regarding hydration and fluid intake monitoring |
| Licensed practical nurse #1 | LPN | Interviewed regarding hydration monitoring |
| Licensed practical nurse #3 | LPN | Interviewed regarding medication administration and communication |
| Registered dietitian | RD | Interviewed regarding dietary compliance and meal preparation |
| Dietary director of operations | DDO | Interviewed regarding dietary operations and meal compliance |
| Nursing home administrator | NHA | Interviewed regarding facility policies and corrective actions |
| Assistant dietary service manager | ADSM | Interviewed regarding food labeling and dating |
| Registered nurse #4 | RN | Interviewed regarding dehydration signs and symptoms |
| Social services director | SSD | Interviewed regarding fall management and IDT meetings |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 31, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements including resident safety, medication administration, nutrition, hydration, and food safety.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse, inadequate supervision to prevent falls, insufficient hydration for residents, significant medication administration errors, failure to follow therapeutic diets, poor food quality and palatability, and unsafe food handling practices in the dietary department.
Deficiencies (8)
F0600: The facility failed to protect residents from resident-to-resident physical abuse involving two residents, with minimal harm or potential for actual harm.
F0689: The facility failed to provide adequate supervision to prevent accidents, resulting in two falls for one resident, including a hip fracture, and failed to investigate the root cause of falls.
F0692: The facility failed to provide sufficient hydration to two residents, did not monitor fluid intake consistently, and failed to ensure hydration needs were met according to care plans.
F0760: The facility failed to prevent significant medication errors for two residents by not administering prescribed medications as ordered and failing to notify physicians or families.
F0803: The facility failed to follow menus correctly, including portion sizes and diet-specific items, resulting in inadequate nutrition and noncompliance with posted menus.
F0804: The facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature, with multiple resident complaints about food quality.
F0808: The facility failed to provide therapeutic diets as prescribed by physicians to two residents, including carbohydrate controlled diets, and failed to follow diet orders consistently.
F0812: The facility failed to ensure food items removed from original packaging were properly labeled and dated, risking contamination and food-borne illness.
Report Facts
Residents reviewed: 32
Residents affected by abuse deficiency: 2
Residents affected by fall supervision deficiency: 1
Residents affected by hydration deficiency: 2
Residents affected by medication errors: 2
Residents affected by therapeutic diet deficiency: 2
Residents affected by food palatability deficiency: Many
Residents affected by food labeling deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding resident supervision and abuse incident |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding supervision, medication administration, and dietary issues |
| RN #2 | Registered Nurse | Interviewed regarding fall interventions for Resident #40 |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding fall assessment and interventions |
| RN #3 | Registered Nurse | Interviewed regarding hydration monitoring |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed regarding hydration assistance |
| Certified Nurse Aide #2 | Certified Nurse Aide (CNA) | Interviewed regarding hydration and fluid intake documentation |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding hydration monitoring |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and communication |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding dietary compliance, therapeutic diets, and food quality |
| Dietary Director of Operations | Dietary Director of Operations (DDO) | Interviewed regarding dietary management and food service issues |
| Cook #2 | Cook | Interviewed regarding meal preparation and portion sizes |
| Assistant Dietary Service Manager | Assistant Dietary Service Manager (ADSM) | Interviewed regarding food labeling and storage |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding overall facility compliance and corrective actions |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 16, 2019
Visit Reason
Routine inspection of Colonial Rehabilitation and Nursing, LLC to assess compliance with regulatory requirements related to resident dignity, safety, care, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident dignity, inadequate assistance with activities of daily living, incomplete assessments after significant changes, medication errors, improper infection control practices, and food quality and safety issues.
Deficiencies (14)
F 0550: The facility failed to ensure residents #15, #57, and #65 were treated with dignity, including failure to inform residents before spraying sanitizing chemicals and not honoring resident #15's wishes regarding going to bed and plugging in her motor scooter.
F 0584: The facility failed to provide clean hand towels and washcloths to residents and maintain clean dining room floors.
F 0604: The facility failed to ensure residents #15 and #67 were free from physical restraints, including improper use of an electric recliner and lack of assessment for wander guard use.
F 0637: The facility failed to complete a comprehensive and accurate assessment of functional capacity after a significant change in condition for resident #70.
F 0659: The facility failed to ensure residents #45 and #277 received care from qualified personnel, including lack of RN assessment after a fall and LPN without IV certification performing PICC line care.
F 0676: The facility failed to provide assistance with activities of daily living for residents #2 and #44, including communication assistance and meal assistance.
F 0677: The facility failed to provide timely incontinent care to resident #4, resulting in prolonged exposure to incontinence and skin redness.
F 0692: The facility failed to ensure sufficient fluid intake to maintain hydration for resident #60, who received inadequate fluids during observed periods.
F 0726: The facility failed to ensure licensed nurses were trained on the use of crash carts, resulting in staff unable to properly operate suction equipment during emergencies.
F 0744: The facility failed to implement person-centered care for resident #49 with dementia, resulting in untreated self-injurious behaviors, lack of communication, and failure to provide preferred activities and protective interventions.
F 0759: The facility failed to ensure medication error rates were below 5%, with a 46.15% error rate observed during medication pass, including late administration and failure to notify physicians.
F 0804: The facility failed to ensure food was palatable, attractive, and served at safe temperatures, with observations of cold, bland, and repetitive meals and poor food quality complaints.
F 0812: The facility failed to maintain sanitary conditions in the kitchen, including improper glove use, cross-contamination, and failure to clean utensils and surfaces properly.
F 0880: The facility failed to follow infection control practices, including improper hand hygiene, failure to disinfect equipment between resident use, and failure to change gloves between dirty and clean procedures.
Report Facts
Medication pass error rate: 46.15
Medication late administration: 3
Medication late administration: 93
Fluid intake: 160
Fluid intake: 1956
Medication late administration: 200
Temperature: 123
Temperature: 104.7
Temperature: 112
Medication error count: 12
Medication pass opportunities: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in dignity and communication findings with Resident #15 and Resident #2 |
| LPN #4 | Licensed Practical Nurse | Performed PICC line care without IV certification for Resident #277 |
| RN #4 | Registered Nurse | Observed medication pass errors and late medication administration for Resident #24 |
| CNA #12 | Certified Nurse Aide | Interviewed about communication with Resident #49 and infection control practices |
| DON | Director of Nursing | Interviewed regarding multiple findings including dignity, medication errors, infection control, and care plans |
| SDC | Staff Development Coordinator | Interviewed about infection control training and crash cart training |
| DM | Dietary Manager | Interviewed about food quality and temperature issues |
| DC #1 | Dietary Cook | Observed and interviewed regarding food temperature and kitchen sanitation |
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