COLONIAL GARDENS NURSING HOME
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2023 1 penalties totaling $15,000
Fine
2021 2 penalties totaling $1,633
Fine
Fine
Health Violations by Year
2025 23 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure that residents are fully informed and understand their health status, care and treatments.
Reasonably accommodate the needs and preferences of each resident.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Assess the resident when there is a significant change in condition
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2024 32 violations
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide enough food/fluids to maintain a resident's health.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Ensure that residents are fully informed and understand their health status, care and treatments.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure medication error rates are not 5 percent or greater.
2023 13 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide and implement an infection prevention and control program.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
2022 30 violations
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide and implement an infection prevention and control program.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate pain management for a resident who requires such services.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Post nurse staffing information every day.
2021 1 violations
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
2019 19 violations
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Assure that each residentβs assessment is updated at least once every 3 months.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Honor each resident's preferences, choices, values and beliefs.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Implement a program that monitors antibiotic use.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Respond appropriately to all alleged violations.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2018 20 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
2017 9 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure a qualified health professional conducts resident assessments.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.