The same week, nurses were pumping oxygen into Resident 61's lungs at more than double the prescribed rate. His doctor had ordered 2 liters per minute as needed for his chronic lung disease. Staff were giving him 4.5 liters continuously, a dangerous overdose that could cause oxygen toxicity and potentially kill him.
Federal inspectors found these and other serious safety failures during a May 2025 inspection of Colonial Gardens Nursing Home on Rosemead Boulevard. The facility's 99 residents faced medication errors, improper feeding tube care, missing discharge notices, and expired drugs stored in medication carts.
Resident 47's call light failure exemplified the facility's communication breakdowns. The resident, who has severe cognitive impairment and needs help with basic daily activities, told inspectors the device "had not worked for months." His care plan specifically required staff to "place the call light within reach" and "encourage Resident 47 to use the bell to call for assistance."
When Certified Nursing Assistant 4 tested the call light, she confirmed it didn't work. "Resident 47 could not call out for assistance if the call light was not working," she told inspectors. The Director of Nursing acknowledged that nursing staff should check call lights every shift to ensure they're functional and within reach.
Another resident, Resident 78, also had a broken call light. When inspectors pushed the button, the indicator light outside the room remained dark. A nursing assistant confirmed the call light "did not work" and said there was potential for the resident's needs to go unmet and for falls to occur.
The oxygen overdose posed even greater immediate danger. Resident 61, who has chronic obstructive pulmonary disease and severe cognitive impairment, was receiving oxygen at 4.5 liters per minute around the clock. His physician had ordered just 2 liters as needed.
Licensed Vocational Nurse 1, who was assigned to care for Resident 61, admitted the treatment didn't follow doctor's orders. She said the resident "should not have been placed on 4.5 LPM continuously because it did not follow the physician's order and placed Resident 61 at risk for oxygen toxicity and carbon dioxide retention."
The Director of Nursing explained that residents with chronic lung disease "were contraindicated to receive high concentrations of oxygen because the resident may not be able to tolerate the oxygen therapy, causing him or her to retain more carbon dioxide which could lead to respiratory distress."
Staff compounded the oxygen error by failing to monitor Resident 61 properly. When a nursing assistant took him to the facility patio without his oxygen, his breathing became labored. Inspectors measured his respiratory rate at 24 breaths per minute — well above the normal range of 12 to 18 — and his oxygen saturation dropped to 87 percent, below the normal 95 to 100 percent.
The nursing assistant admitted she "should have informed" the licensed nurse before removing the resident's oxygen and taking him outside. The Director of Nursing said this "placed Resident 61 at risk for an episode of desaturation, respiratory distress, and a medical emergency."
Medication management failures extended beyond oxygen therapy. Resident 17 missed 40 consecutive doses of calcium supplements over 20 days because the order wasn't transcribed onto medication administration records. The Licensed Vocational Nurse responsible for the resident's care said this "put Resident 17 at risk of mood changes, weakness, and pain in the bones."
Staff also failed to properly document controlled substances. For Resident 76, nurses administered narcotic pain medications and anxiety drugs but didn't sign required narcotic count sheets. The discrepancies included two missing signatures for tramadol, two for lorazepam, and one for hydrocodone-acetaminophen.
Licensed Vocational Nurse 1 admitted she was "too busy" to sign the sheets after giving medications. The Director of Nursing called this "a medication error" that posed risks for miscounting and potential overdoses.
Feeding tube safety violations put another resident at risk. Resident 40, who receives nutrition through a gastrostomy tube, was observed lying nearly flat while receiving feedings. Doctor's orders and facility policy required the head of his bed to be elevated 30 to 45 degrees during and after feedings to prevent aspiration pneumonia.
Licensed Vocational Nurse 3 acknowledged the bed positioning "was not acceptable" when she found the resident receiving tube feedings while lying flat. The Director of Nursing said proper positioning was essential "to prevent complications, such as aspiration."
Infection control lapses created additional hazards. Resident 40's urinary catheter drainage bag was observed touching the floor on multiple occasions. Licensed Vocational Nurse 4 explained this placement "placed Resident 40 at risk for urinary tract infection" because "bacteria could enter the urinary catheter drainage bag when touching the floor."
Food safety problems in the kitchen threatened all residents. Inspectors found personal food items stored in a facility refrigerator, along with opened bottles of chocolate syrup, caramel drizzle, whipped cream, and chopped onions that lacked required date labels. An opened ice cream carton in the freezer was also unlabeled.
The Dietary Supervisor acknowledged these violations "placed all residents at risk for cross contamination and food borne illnesses."
Assessment and care planning failures left residents without proper treatment plans. Resident 54, who takes antidepressant medication for depression, had no care plan addressing his diagnosis. The MDS Nurse said this meant "the facility staff would not be able to provide quality care and services for their needs."
Similarly, Resident 17 lacked care plans for vitamin D deficiency, depression medication, and anxiety drugs despite active orders for these conditions. The MDS Nurse explained that without care plans, "residents were at risk for side effects and staff needed to know the appropriate interventions."
Administrative failures compounded clinical problems. When Resident 98 was discharged in February, staff failed to provide required discharge notices to the resident or the state ombudsman. The Director of Nursing said the missing documentation made it "unclear where the resident went."
The facility also failed to complete required assessments within mandated timeframes. Resident 40's significant change assessment was due within 14 days of readmission but wasn't completed. The MDS Nurse acknowledged this delayed proper care planning.
Expired medications posed additional safety risks. Inspectors found bottles of expired allergy medication in a medication cart and expired antipsychotic medication in a refrigerator. The Director of Nursing said administering expired drugs "would be a medication error" because the medications lose effectiveness.
The inspection revealed systemic problems with monitoring requirements for blood-thinning medications. Both Resident 17 and Resident 29 were prescribed anticoagulants but weren't receiving required monitoring for bleeding complications. Licensed nurses admitted they weren't aware of monitoring orders or care plan requirements.
Physical plant violations affected resident privacy and space. Four bedrooms housed six residents each, exceeding the four-resident maximum, while eight two-person rooms provided less than the required 80 square feet per resident.
The May 2025 inspection resulted in citations for 14 federal regulations covering resident safety, medication management, infection control, and facility operations. The violations affected residents with complex medical needs including dementia, chronic lung disease, depression, and feeding difficulties.
Colonial Gardens' failures illustrate how basic safety breakdowns — broken call lights, medication errors, improper positioning — can cascade into life-threatening situations for vulnerable nursing home residents who depend entirely on staff for their care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Gardens Nursing Home from 2025-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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