Colonial Park Rehabilitation And Nursing Center

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and deemed that the medication was not given, it would be a medication error. They were not aware of any investigations done about the missing medications administrations. They stated given it was only five doses missing, they were not sure it was a significant medication error. If the provider was notified of the missing medications, there should be a note from the person who contacted the provider. The note should include why they were contacted and what the decision was from the conversation. They expected something in every box of the Medication Administration Record. The Unit Managers should be reviewing the Medication Administration Records and should have investigated it, but they were unable to speak to what happen.

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)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Park Rehabilitation and Nursing Center

950 Floyd Avenue Rome, NY 13440

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

trough on 04/14/2025. On 04/14/2025, the pharmacy followed up and the facility stated they were going to draw the trough on 04/16/2025. On 4/18/2025, the facility stated the lab sat too long and needed to be redrawn and would be drawn again on 04/21/2025. On 4/21/2025, the facility stated the trough was high and the resident was sent to the hospital, and the vancomycin was put on hold. 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

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