On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 9 Google reviews

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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare Special Focus status indicates a history of serious quality problems and heightened oversight. Review the latest inspection records, ask what corrective actions remain open, and visit in person before deciding.
Colonial Oaks Skilled Nursing and Rehabilitation receives highly polarized feedback, with praise for its rehabilitation therapy program and some nursing staff, contrasted by severe allegations regarding hygiene and neglect. Families report inconsistent experiences, with some highlighting a clean environment and compassionate care, while others describe significant failures in basic patient care and cleanliness.
Quality Themes
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Concerns
Rating Trends
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Distribution · 11 analyzed
Personalized based on this facility's data
Key Review Excerpts
“The rehab is excellent! (thanks Lydia) The rehab nurses are extremely tentative and super friendly. Mom received intense therapy 5 days a week, for multiple times a day.”
“The patients that can't get up and go to the bathroom have their diapers changed twice daily. The daytime CNAs get the patients up and clean them after they have laid in their own waste be it urine or stool ALL NIGHT.”
“The staff is literally her family, these Nurses and CNA are angles in our eyes .. Class act all the way”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
14
measures
3
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Residents whose walking got worse
Residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families have filed complaints that triggered inspections revealing serious concerns about abuse reporting and care standards. The facility shows recurring problems with care planning, medication management, and food safety across multiple surveys from 2023 to 2025. While all deficiencies have reported correction dates, the pattern of repeated issues in core care areas suggests ongoing operational challenges that families should investigate thoroughly during visits.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Federal Penalties
Fine
Jun 5, 2025
$66,170
Colonial Oaks Skilled Nursing and Rehabilitation
for profit
Priority Management
38 facilities nationwide
Chain avg rating: 2.7/5 · Rank 32 of 38 (Lowest rating)
Owners
Sdb Holdings
Owner · Organization
Bauder, William
Owner (parent company)
Boulware, Douglas
Owner (parent company)
Boulware, Steven
Owner (parent company)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
9 reviews from families & visitors
Official Website
Visit colonialoaksnursinghome.com
Medicare data downloads
Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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