Colonial Gardens Nursing Home: Broken Window Violation - CA
The resident, identified in inspection records only as Resident 2, had the gap in their window covered with a piece of wood as a temporary measure. Cold air was coming through. The Director of Nursing acknowledged that the situation made the resident uncomfortable and said the window replacement should have been treated as an immediate priority.
It wasn't.
The Director of Nursing told inspectors the maintenance aide should have installed the new window as soon as it was ready, and that the weekend was not an acceptable reason to delay. The window had been available. Nobody had put it in.
The Director of Nursing put it plainly: the facility is the residents' home, and it should be kept clean, safe, and in working condition. That standard, by the facility's own account, had not been met for Resident 2.
The inspection was triggered by a complaint, not a routine visit. Inspectors cited the violation under the federal standard requiring nursing homes to maintain a safe, clean, comfortable, and homelike environment for residents. The level of harm was recorded as minimal harm or potential for actual harm, and the violation was found to affect a small number of residents.
The facility's own internal policies, dating to 2001, spell out that the maintenance department is responsible for keeping the building and its equipment safe and operational at all times, and that repair priorities are supposed to be established and followed. A separate policy on homelike environment states residents are to be provided with surroundings that are safe, clean, comfortable, and homelike.
A broken window covered with wood, with cold air moving through the gap, did not meet that standard. The facility's director of nursing did not dispute it.
What the inspection record does not say is how long Resident 2 lived with the wood-covered window before inspectors arrived. It does not say whether anyone had formally flagged the problem before the complaint was filed. It does not say whether the window had been replaced by the time inspectors left.
What it does say is that a person was sleeping, presumably, in a room where the window didn't close properly, in a facility whose own written policies required exactly the kind of prompt repair that hadn't happened.
The Director of Nursing's comments to inspectors carried an implicit acknowledgment that the system had failed at a basic level. The replacement window existed. The need was recognized as urgent. The resident's discomfort was foreseeable. And still, the repair waited.
Nursing homes are licensed and regulated on the premise that residents who can no longer fully care for themselves will be housed in conditions that are at minimum safe and comfortable. For Resident 2, the gap between that premise and the reality in their room was, for some period of time, measurable in cold air.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Gardens Nursing Home from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 3, 2026 · Our methodology
COLONIAL GARDENS NURSING HOME in PICO RIVERA, CA was cited for violations during a health inspection on November 18, 2025.
The resident, identified in inspection records only as Resident 2, had the gap in their window covered with a piece of wood as a temporary measure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.