Colonial Park Rehabilitation And Nursing Center
COLONIAL PARK REHABILITATION AND NURSING CENTER in ROME, NY — inspection on December 1, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a telephone interview on 10/20/2025 at 3:15 PM, Physician #1 stated they were responsible for the oversight of residents' medical care, review of hospital discharge recommendations, and management of medications upon admission.
Hospital discharge recommendations were reviewed promptly upon a resident's admission.
They reviewed all medication recommendations by the hospital and ensured nursing staff implemented them. Resident #1 was admitted on vancomycin, the treatment course was to continue for approximately six weeks, with vancomycin trough levels (blood test used for monitoring to ensure the antibiotic is effective and to minimize the risk of toxicity) monitored daily in residents with renal impairment or at least every three days. If a resident missed an intravenous antibiotic dose, they expected immediate notification from nursing staff and documentation of the communication.
They were not notified Resident #1 missed any doses of vancomycin or cefepime. It was a significant medication error and should have been reported.10NYCRR 415.12(m)(2)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Colonial Park Rehabilitation and Nursing Center
950 Floyd Avenue Rome, NY 13440
SUMMARY STATEMENT OF DEFICIENCIES
During a telephone interview on 10/16/2025 at 11:58 AM, Registered Nurse #5 stated the registered nurses in the facility drew the blood for the labs from the peripherally inserted central catheters (venous access).
The lab order was completed, and they called the lab to come get the specimens.
During an interview on 10/16/2025 at 12:57 PM, Assistant Director of Nursing #7 stated labs went out on Monday, Wednesday, and Friday.
Orders were usually placed with a 3-day window so they could be drawn on one of those days. A list of who needed labs drawn was provided to the phlebotomist (person who draws blood).
The phlebotomist completed a venipuncture (drawing blood with a needle) for a resident with a peripherally inserted central catheter, or the registered nurse could draw the blood and give the vial to the phlebotomist to bring to the lab.
The vancomycin trough should be drawn before the next dose was given. Resident #1 got vancomycin at 9:00 AM and 9:00 PM, the trough should be drawn at 8:00 AM.
The 1:00 PM or 4:00 PM draw would not be appropriate.
The trough was meant to see the lowest level of vancomycin in the body system, so it needed to be before the next dose. If the trough was not done at the appropriate time it could result in a higher value due to the timing of the dose completion.
The 04/14/2025 laboratory order should have been done, and they were not sure why it was not.
Upon review of the records, Assistant Director of Nursing #7 stated the only vancomycin trough they could find was on 04/18/2025.
There was no trough done on 04/14/2025.
There was a note on 04/15/2025 documenting labs were drawn, but did not specify if the labs were for vancomycin.
There were no laboratory results for 04/14/2025 in the computer.
During an interview on 10/16/2025 at 1:40 PM, the Director of Nursing #3 stated the vancomycin trough was outlined on the hospital discharge paperwork. If it was due on Tuesday, it was drawn one hour before the next dose. Resident #1 was on intravenous vancomycin.
They stated they did not remember the resident and the only information they had was based on what they read in the chart.
Peripheral inserted central catheter laboratory draws were done by a registered nurse. If the resident had an order for a vancomycin draw on 04/14/2025, it should have been drawn.
They did not know why it was not done.
The registered nurses knew if there was a vancomycin trough order, it should be drawn before the next dose was given.
They stated 1:00 PM and 4:00 PM were not appropriate time to draw a vancomycin trough if the resident got their antibiotics at 9:00 AM and 9:00 PM. It should have been drawn at 8:00 AM.
During a telephone interview on 10/20/2025 at 3:15 PM, Physician #1 stated Resident #1 was admitted on vancomycin, the treatment course was to continue for approximately six weeks.
Vancomycin trough levels should be monitored daily in residents with renal impairment or at least every three days.
Vancomycin trough levels must be drawn approximately one hour before the next scheduled dose. A trough obtained at 1:00 PM would not be appropriate if it did not align with the dosing schedule.
Additionally, waiting four days to draw a trough was not acceptable and they should have been notified.
Elevated vancomycin levels, 40-50 micrograms/ milliliter could cause renal impairment, regardless of pre-existing kidney disease, failure to obtain the vancomycin trough every three days could lead to nephrotoxicity. If they had had the trough levels, they would have stopped the medication. 10 NYCRR 415.20
Facility ID: