Inspection Reports for
Colonial Skilled Nursing Facility
2090 N Congress Ave, West Palm Beach, FL 33401, FL, 33401
Back to Facility Profile4 Reports
Inspection Report — Aug 6, 2026
Complaint Investigation
Date: Aug 6, 2026
Visit Reason
The page covers the inspection history of Colonial Assisted Living at Palm Beach LLC, including routine and complaint investigations.
Findings
The facility has a history of 61 deficiencies across 54 visits, with 6 serious deficiencies and 10 legal actions totaling $50,250 in fines.
Citations (61)
Resident Care - Rights & Facility Procedures — cited April 1, 2026, corrected August 6, 2026
Use of Personnel; Emergency Care (Aed) — cited April 1, 2026, corrected August 6, 2026
Training - Hiv/aids — cited April 1, 2026, corrected August 6, 2026
Physical Plant - Safe Living Environ/other — cited April 1, 2026, corrected August 6, 2026
Records - Staff — cited April 1, 2026, corrected August 6, 2026
Resident Care - Rights & Facility Procedures — cited November 9, 2023, corrected March 27, 2024
Medication - Assistance With Self-admin — cited November 9, 2023, corrected March 27, 2024
Medication - Storage and Disposal — cited November 9, 2023, corrected March 27, 2024
Training - Adrd — cited November 9, 2023, corrected March 27, 2024
Food Service - Dietary Standards — cited November 9, 2023, corrected March 27, 2024
Resident Care - Supervision — cited May 16, 2022, corrected June 17, 2022
Staffing Standards - Administrators — cited May 16, 2022, corrected June 17, 2022
Physical Plant - Safe Living Environ/other — cited May 16, 2022, corrected June 17, 2022
Training - First Aid and Cpr — cited February 2, 2022, corrected April 29, 2022
Records - Facility — cited February 2, 2022, corrected April 29, 2022
Emergency Management Planning — cited April 12, 2021, corrected June 18, 2021
Resident Care - Elopement Standards — cited November 21, 2019, corrected January 28, 2020
Medication - Records — cited November 21, 2019, corrected January 28, 2020
Medication - Labeling and Orders — cited November 21, 2019, corrected January 28, 2020
Staffing Standards - Staff — cited November 21, 2019, corrected January 28, 2020
Training - Hiv/aids — cited November 21, 2019, corrected January 28, 2020
Training - Assis Self-admin Meds & Med Mgmt — cited November 21, 2019, corrected January 28, 2020
Physical Plant - Safe Living Environ/other — cited November 21, 2019, corrected January 28, 2020
Background Screening-compliance Attestation — cited November 21, 2019, corrected January 28, 2020
Food Service - Dietary Standards — cited August 13, 2019, corrected November 21, 2019
Resident Care - Rights & Facility Procedures — cited July 1, 2019, corrected November 21, 2019
Pharmacy & Dietary; Uncorrected Deficiencies — cited December 18, 2018, corrected February 18, 2019
Admissions - Continued Residency — cited October 25, 2018, corrected December 18, 2018
Resident Care - Third Party Services — cited October 25, 2018, corrected December 18, 2018
Medication - Records — cited October 25, 2018, corrected February 18, 2019
Medication - Labeling and Orders — cited October 25, 2018, corrected December 18, 2018
Emergency Plan Approval — cited September 10, 2018, corrected December 18, 2018
Admissions - Health Assessment — cited July 11, 2018, corrected September 10, 2018
Admissions - Continued Residency — cited July 11, 2018, corrected September 10, 2018
Resident Care - Supervision — cited July 11, 2018, corrected September 10, 2018
Medication - Administration — cited July 11, 2018, corrected September 10, 2018
Medication - Records — cited July 11, 2018, corrected September 10, 2018
Medication - Labeling and Orders — cited July 11, 2018, corrected September 10, 2018
Physical Plant - Safe Living Environ/other — cited July 11, 2018, corrected September 10, 2018
Training - Staff In-service — cited November 21, 2017, corrected January 25, 2018
Food Service - Dietary Standards — cited November 21, 2017, corrected January 25, 2018
Physical Plant - Safe Living Environ/other — cited November 21, 2017, corrected January 25, 2018
Risk Mgmt & Qa; Adverse Incident Report — cited November 21, 2017, corrected January 25, 2018
Medication - Labeling and Orders — cited October 27, 2017, corrected January 25, 2018
Physical Plant - Safe Living Environ/other — cited October 27, 2017, corrected January 25, 2018
Resident Care - Supervision — cited December 8, 2016, corrected January 20, 2017
Medication - Assistance With Self-admin — cited December 8, 2016, corrected January 23, 2017
Medication - Records — cited December 8, 2016, corrected January 23, 2017
Medication - Labeling and Orders — cited December 8, 2016, corrected January 23, 2017
Risk Mgmt & Qa; Adverse Incident Report — cited December 8, 2016, corrected January 20, 2017
Resident Care - Rights & Facility Procedures — cited October 31, 2016, corrected January 20, 2017
Admissions - Continued Residency — cited October 1, 2015, corrected December 23, 2015
Medication - Assistance With Self-admin — cited October 1, 2015, corrected December 23, 2015
Physical Plant - Safe Living Environ/other — cited October 1, 2015, corrected December 23, 2015
Resident Care - Supervision — cited November 26, 2013, corrected January 30, 2014
Medication - Storage and Disposal — cited November 26, 2013, corrected January 30, 2014
Medication - Labeling and Orders — cited November 26, 2013, corrected January 30, 2014
Admissions - Continued Residency — cited February 18, 2013, corrected May 21, 2013
Resident Care - Rights & Facility Procedures — cited February 18, 2013, corrected May 21, 2013
Medication - Records — cited February 18, 2013, corrected May 21, 2013
Records - Facility — cited February 18, 2013, corrected May 21, 2013
Report Facts
Inspections: 54
Visits with deficiencies: 20
Clean visits: 17
Deficiencies: 61
Serious deficiencies: 6
Legal actions: 10
Total fines: 50250
Inspection Report — May 15, 2025
Routine
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.
Citations (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 — Feb 1, 2024
Complaint Investigation
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.
Citations (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 — Oct 6, 2022
Routine
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.
Citations (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 |
3 CMS Surveys
CMS Survey — Oct 6, 2022
Oct 6, 2022
CMS Survey — Feb 1, 2024
Feb 1, 2024
CMS Survey — May 15, 2025
May 15, 2025
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