Colony Center for Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Colony Center for Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 1, 2026

  Based on interview and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#5), out of a total sample of 18 residents, resulting in a decline in medical status and hospitalization. Specifically, the facility failed to ensure staff assessed and managed gastrointestinal symptoms indicative of constipation, resulting in hospitalization for stercoral colitis (inflammation of the intestinal walls caused by hardened stool in the colon) and fecal impaction (a severe form of constipation where stool becomes stuck in the colon/rectum).Findings include:Review of the facility's policy titled Bowel Regimen, revised 2/2024, indicated, but was not limited to, the following:-CNA (Certified Nursing Assistant) is… […]

• Actual harm, isolatedF658Jul 15, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, and on 6/23/24 during the overnight shift had been heard calling out for help and was found on the floor by two Certified Nurse Aides (CNAs) after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of practice, when although Nurse #1 went to Resident #1's room with the two CNA's to check him/her, after a brief assessment Nurse #1 assisted the CNA's with lifting him/her off the floor and putting him/her back in to bed. […]

• Actual harm, isolatedF697Jan 18, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate pain management for one Resident (#53), out of a total sample of 20 residents, when the facility was unable to reach the Resident's primary care physician for new pain management orders based on Hospice recommendations, resulting in the Resident suffering very severe pain of 7/8 on a scale of 1-10 with 10 being the worst pain for more than 24 hours after the Hospice recommendation was made. […]

• Actual harm, isolatedF656Jun 29, 2022

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had right sided paralysis and was assessed by nursing as requiring physical assistance of one to two staff members for transfers, the Facility failed to ensure interventions identified in his/her plan of care related to the need for physical assistance during a transfer was appropriately implemented by staff. On 06/13/22, Certified Nurse Aide (CNA) #1 was not positioned correctly in order to physically assist and help facilitate a safe transfer for Resident #1 and remained behind Resident #1, in back of his/her wheelchair during the transfer. […]

• Actual harm, isolatedF689Jun 29, 2022

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had right sided paralysis and was assessed by nursing as requiring one to two staff members to provide physical assistance to safety transfer, the Facility failed to ensure Resident #1 was provided with the appropriate level of staff assistance in an effort to maintain his/her safety and prevent an incident/accident resulting in an injury. On 06/13/21, Certified Nurse Aide (CNA) # 1 went to assist Resident #1 back to bed from his/her wheelchair. CNA #1, who should have been standing in front of the wheelchair next to Resident #1, stood behind Resident #1's wheelchair during a transfer and was therefore not in a position to physically assist him/her during the transfer. […]