Inspection Reports for
Colonial Skilled Nursing Facility
2090 N Congress Ave, West Palm Beach, FL 33401, FL, 33401
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
7.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and inspection statuses.
Findings
Across the inspections, the facility had a mix of no deficiencies, deficiencies cited, and deficiencies corrected. Several complaint and standard inspections cited deficiencies, while many complaint inspections found no deficiencies.
Report Facts
Inspections on page: 66
Inspection Report
Routine
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
No deficiencies noted during this inspection.
Findings
No deficiencies noted during this inspection.
Inspection Report
Routine
Deficiencies: 10
Date: May 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, dietary services, and facility management.
Findings
The facility was found deficient in multiple areas including failure to ensure functional wheelchair locks for a resident, lack of assessment and assistance with advance directives, failure to conduct interdisciplinary care plan meetings, inadequate interventions for eating independence, improper nail care, inaccurate nurse staffing postings, failure to provide appropriate therapeutic diets and menus, failure to provide physician-ordered liquid consistencies, and deficiencies in infection prevention and control practices including outdated water management plan and poor linen and equipment sanitation.
Deficiencies (10)
Failed to ensure a functional wheelchair lock for Resident #17, resulting in wheelchair rolling away during meals.
Failed to assess for and assist in formulating advance directives upon admission for Resident #17.
Failed to ensure interdisciplinary team participation and care plan meetings for 5 residents reviewed.
Failed to implement timely interventions and adaptive equipment to ensure eating independence for Resident #17.
Failed to ensure proper nail care for Resident #6, with long and soiled fingernails observed.
Failed to post accurate daily nurse staffing information including number of nursing staff and correct date.
Failed to ensure menus met nutritional needs and were properly developed and followed for mechanical soft diet residents.
Failed to provide physician ordered liquid consistencies for Resident #17, who was downgraded to nectar liquids but served thin liquids.
Failed to ensure recommended diet upgrade was followed and communicated to staff for Resident #16.
Failed to update water management plan to include current team members, maintain linens and laundry area in clean condition, and disinfect blood pressure equipment after use.
Report Facts
Residents reviewed for care plan meetings: 5
Days nurse staffing information missing actual number: 4
Days nurse staffing information posted for incorrect date: 1
Residents affected by mechanical soft diet menu deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Occupational Therapist Assistant (COTA) | Named in wheelchair lock and eating assistance findings for Resident #17 |
| Staff B | Certified Occupational Therapist Assistant (COTA) | Named in adaptive equipment assessment for Resident #17 |
| Staff D | Licensed Practical Nurse (LPN) | Named in nail care deficiency for Resident #6 |
| Staff E | Registered Nurse (RN) | Named in eating assistance and medication administration findings |
| Staff G | Certified Nursing Assistant (CNA) | Named in liquid consistency and meal ticket findings |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including wheelchair lock, advance directives, care plan meetings, diet orders, and infection control |
| Dietary Manager | Dietary Manager | Named in menu and diet preparation deficiencies |
| Maintenance Director | Maintenance Director | Named in infection control and water management plan deficiencies |
| Business Office Manager (BOM) | Business Office Manager | Named in advance directives assessment finding |
Inspection Report
Deficiencies: 0
Date: Oct 18, 2024
Visit Reason
No deficiencies noted during this inspection.
Findings
No deficiencies noted during this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 1, 2024
Visit Reason
The inspection was conducted based on complaints and observations regarding resident care, medication administration, and facility conditions at Colonial Skilled Nursing Facility LLC.
Complaint Details
The visit was complaint-related, triggered by multiple resident complaints and observations regarding facility services, including a non-functioning television, medication administration errors, and unsanitary food preparation.
Findings
The facility was found deficient in multiple areas including failure to ensure a working television for a resident, improper medication administration and documentation, inadequate nursing competencies, unsanitary food preparation conditions, improper eye drop administration, and failure to comply with binding arbitration agreement requirements.
Deficiencies (6)
Failed to ensure a working television for 1 of 1 sampled resident who voiced a complaint (Resident #80).
Failed to ensure care and services as per resident choice for 1 of 2 sampled residents observed who received blood sugar level checks (Resident #10).
Failed to ensure nurses and nurse aides have appropriate competencies to care for every resident, including medication administration errors and documentation issues (Residents #81, #17, #25, #130, #12, #4, #13, #26).
Medication error rate was 7.14 percent with two medication errors identified affecting 2 of 7 residents observed (Residents #8 and #4).
Failed to prepare and serve food in a sanitary manner affecting all residents who eat their meals in the facility.
Failed to ensure Binding Arbitration Agreements complied with all regulatory requirements affecting all residents who signed the facility's current arbitration agreement.
Report Facts
Medication error rate: 7.14
Medication administration opportunities observed: 28
Residents affected by medication errors: 2
Residents observed for medication administration: 7
Days antibiotic prescribed without stop date: 7
Brief Interview for Mental Status (BIMS) scores: 14
Brief Interview for Mental Status (BIMS) scores: 9
Brief Interview for Mental Status (BIMS) scores: 3
Brief Interview for Mental Status (BIMS) scores: 15
Medication documentation errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Direct Care Nurse | Named in findings related to non-functioning TV for Resident #80 and medication administration errors. |
| Administrator | Named in findings related to TV issues and facility administration. | |
| Social Services Director | Assisted with fixing Resident #80's TV without formal training. | |
| Staff A | Licensed Practical Nurse (LPN) | Involved in medication administration error with Resident #10. |
| Director of Nursing | DON | Interviewed regarding medication errors and facility policies. |
| Consultant Pharmacist | Interviewed regarding antibiotic stewardship and medication documentation. | |
| Certified Dietary Manager | Acknowledged unsanitary kitchen conditions. |
Inspection Report
Routine
Deficiencies: 5
Date: Nov 9, 2023
Visit Reason
Multiple Class 3 deficiencies related to resident care, medication, training, and food service.
Findings
Multiple Class 3 deficiencies related to resident care, medication, training, and food service.
Deficiencies (5)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0055 — MEDICATION - STORAGE AND DISPOSAL
Tag A0086 — TRAINING - ADRD
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Inspection Report
Routine
Deficiencies: 6
Date: Oct 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, activities, nutrition, medication administration, and sanitation at Colonial Skilled Nursing Facility LLC.
Findings
The facility failed to develop baseline care plans for newly admitted residents, hold timely interdisciplinary care plan meetings, provide ongoing activities for residents, follow weight monitoring policies, ensure proper medication administration documentation, and properly dispose of garbage and refuse.
Deficiencies (6)
Failed to develop baseline care plan summaries with initial goals, medication summaries, dietary instructions, and services for newly admitted residents.
Failed to ensure timely care plan meetings with required interdisciplinary team members for 7 of 13 reviewed residents.
Failed to provide ongoing activities to meet the needs of Resident #16.
Failed to follow policy related to weight monitoring for Resident #16 who had significant weight loss.
Failed to ensure nurse competency in medication administration and documentation for Residents #19 and #9.
Failed to properly dispose of garbage and refuse; garbage observed around trash compactor.
Report Facts
Residents reviewed for care plan meetings: 13
Residents sampled for baseline care plan summaries: 4
Weight loss percentage: 9.46
Medication doses administered: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Failed to document medication administration and administer medications at scheduled times for Residents #19 and #9 |
| Regional Dietician | Interviewed regarding weight monitoring and supplementation for Resident #16 | |
| DON | Director of Nursing | Acknowledged deficiencies in weight monitoring and resident stimulation activities |
| Activities Director | Interviewed about lack of documented activities for Resident #16 | |
| Social Service Director | Interviewed about scheduling and attendance of care plan meetings | |
| Dietary Manager | Acknowledged garbage observed around trash compactor |
Inspection Report
Complaint
Deficiencies: 3
Date: May 16, 2022
Visit Reason
Three severity 1 deficiencies related to resident care, staffing, and physical plant.
Findings
Three severity 1 deficiencies related to resident care, staffing, and physical plant.
Deficiencies (3)
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0077 — STAFFING STANDARDS - ADMINISTRATORS
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Inspection Report
Complaint
Deficiencies: 2
Date: Feb 2, 2022
Visit Reason
Two Class 3 deficiencies related to training and records.
Findings
Two Class 3 deficiencies related to training and records.
Deficiencies (2)
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0160 — RECORDS - FACILITY
Inspection Report
Complaint
Deficiencies: 1
Date: Apr 12, 2021
Visit Reason
One unclassified deficiency related to emergency management planning.
Findings
One unclassified deficiency related to emergency management planning.
Deficiencies (1)
Tag CZ830 — EMERGENCY MANAGEMENT PLANNING
Inspection Report
Standard
Deficiencies: 8
Date: Nov 21, 2019
Visit Reason
Multiple Class 3 deficiencies related to resident care, medication, staffing, training, physical plant, and background screening.
Findings
Multiple Class 3 deficiencies related to resident care, medication, staffing, training, physical plant, and background screening.
Deficiencies (8)
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0054 — MEDICATION - RECORDS
Tag A0056 — MEDICATION - LABELING AND ORDERS
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0082 — TRAINING - HIV/AIDS
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Inspection Report
Complaint
Deficiencies: 1
Date: Aug 13, 2019
Visit Reason
One Class 3 deficiency related to food service dietary standards.
Findings
One Class 3 deficiency related to food service dietary standards.
Deficiencies (1)
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Inspection Report
Complaint
Deficiencies: 1
Date: Jul 1, 2019
Visit Reason
One Class 3 deficiency related to resident care rights and facility procedures.
Findings
One Class 3 deficiency related to resident care rights and facility procedures.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Complaint
Deficiencies: 1
Date: Dec 18, 2018
Visit Reason
One Class 3 deficiency related to pharmacy and dietary uncorrected deficiencies.
Findings
One Class 3 deficiency related to pharmacy and dietary uncorrected deficiencies.
Deficiencies (1)
Tag A0058 — PHARMACY & DIETARY; UNCORRECTED DEFICIENCIES
Inspection Report
Complaint
Deficiencies: 4
Date: Oct 25, 2018
Visit Reason
Multiple Class 3 deficiencies related to admissions, resident care, medication, and labeling.
Findings
Multiple Class 3 deficiencies related to admissions, resident care, medication, and labeling.
Deficiencies (4)
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0031 — RESIDENT CARE - THIRD PARTY SERVICES
Tag A0054 — MEDICATION - RECORDS
Tag A0056 — MEDICATION - LABELING AND ORDERS
Inspection Report
Monitor
Deficiencies: 1
Date: Sep 10, 2018
Visit Reason
One Class 3 deficiency related to emergency plan approval.
Findings
One Class 3 deficiency related to emergency plan approval.
Deficiencies (1)
Tag A0181 — EMERGENCY PLAN APPROVAL
Inspection Report
Complaint
Deficiencies: 7
Date: Jul 11, 2018
Visit Reason
Multiple Class 3 deficiencies related to admissions, resident care, medication, and physical plant.
Findings
Multiple Class 3 deficiencies related to admissions, resident care, medication, and physical plant.
Deficiencies (7)
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0053 — MEDICATION - ADMINISTRATION
Tag A0054 — MEDICATION - RECORDS
Tag A0056 — MEDICATION - LABELING AND ORDERS
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Inspection Report
Standard
Deficiencies: 4
Date: Nov 21, 2017
Visit Reason
Multiple Class 3 deficiencies and one Class 4 deficiency related to training, food service, physical plant, and risk management.
Findings
Multiple Class 3 deficiencies and one Class 4 deficiency related to training, food service, physical plant, and risk management.
Deficiencies (4)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Tag A0165 — RISK MGMT & QA; ADVERSE INCIDENT REPORT
Inspection Report
Monitor
Deficiencies: 2
Date: Oct 27, 2017
Visit Reason
Two Class 3 deficiencies related to medication labeling and physical plant safety.
Findings
Two Class 3 deficiencies related to medication labeling and physical plant safety.
Deficiencies (2)
Tag A0056 — MEDICATION - LABELING AND ORDERS
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Inspection Report
Complaint
Deficiencies: 5
Date: Dec 8, 2016
Visit Reason
Multiple deficiencies with severity 2 and Class 3 related to resident care, medication, and risk management.
Findings
Multiple deficiencies with severity 2 and Class 3 related to resident care, medication, and risk management.
Deficiencies (5)
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0054 — MEDICATION - RECORDS
Tag A0056 — MEDICATION - LABELING AND ORDERS
Tag A0165 — RISK MGMT & QA; ADVERSE INCIDENT REPORT
Inspection Report
Complaint
Deficiencies: 1
Date: Oct 31, 2016
Visit Reason
One Class 3 deficiency related to resident care rights and facility procedures.
Findings
One Class 3 deficiency related to resident care rights and facility procedures.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Standard
Deficiencies: 3
Date: Oct 1, 2015
Visit Reason
Multiple Class 3 deficiencies related to admissions, medication, and physical plant.
Findings
Multiple Class 3 deficiencies related to admissions, medication, and physical plant.
Deficiencies (3)
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Inspection Report
Standard
Deficiencies: 3
Date: Nov 26, 2013
Visit Reason
Multiple Class 3 deficiencies related to resident care and medication.
Findings
Multiple Class 3 deficiencies related to resident care and medication.
Deficiencies (3)
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0055 — MEDICATION - STORAGE AND DISPOSAL
Tag A0056 — MEDICATION - LABELING AND ORDERS
Inspection Report
Complaint
Deficiencies: 4
Date: Feb 18, 2013
Visit Reason
Multiple Class 3 deficiencies related to admissions, resident care, medication, and records.
Findings
Multiple Class 3 deficiencies related to admissions, resident care, medication, and records.
Deficiencies (4)
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Tag A0054 — MEDICATION - RECORDS
Tag A0160 — RECORDS - FACILITY
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