Colonial Gardens Nursing Home

F-F865.

Findings:

During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the Director of Nursing (DON), the facility's QAPI Plan, dated 4/1/2024 to 4/30/2024, was reviewed. The plan indicated that the facility planned to improve immunizations, enhanced barrier precautions, and closed discharge charts. There were no documents that indicated an outline of specific interventions and there was no indication that progress was monitored.

During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the DON, the facility's QAPI Plan, dated 5/1/2024 to 5/31/2024/1/2024 was reviewed. The plan indicated the facility planned to improve the Fall Prevention Program and Informed Consents. The plan indicated the Medical Records Department, and the Nursing Department would create a long to track when consents are obtained. There was no documentation provided to indicate a log was created or that progress was monitored.

During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the Director of Nursing DON, the facility's QAPI Plan, dated 6/1/2024 to 6/30/2024, was reviewed. The QAPI Plan indicated the facility was to replace the facility's old roof. The DON stated that department heads usually talked about issues the facility had and they all work together to develop a plan of action.

During an interview, on 6/27/2024, at 2:40 p.m., with the DON, the DON stated that the facility could not effectively improve issues within the facility without the collection of data and outcomes to track the facility's progress.

A review of the facility's Policy and Procedure (P&P), titled QAPI (undated), indicated the facility was to monitor existing Quality Improvement and Quality Measures (QI/QM) results, internal monitors for fall, utilization of antipsychotic medications, infection control surveillance, safety, incident/accidents, and pharmacy. The P&P indicated the QAPI teams analyzed data regularly, monthly reports and graphs were published, logs were kept up to date, and minutes of all (QAPI) meetings were maintained.

A review of the facility's P&P, titled QAPI Compliance (undated), indicated the facility was to establish measurable outcomes focused criteria to use in their efforts at uncovering areas that may adversely impact

the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47679 potential for actual harm Based on interview and record review, the facility failed to implement an effective infection prevention control Residents Affected - Many program for all residents by failing to maintain and complete the infection surveillance documentation.

This deficient practice had the potential to cause the spread of infection causing organisms amongst all staff and/or residents.

Findings:

During a concurrent interview and record review on 6/25/2024 at 9:46 a.m., with the Infection Preventionist Nurse (IPN), the facility's Infection Surveillance Binder, dated 2024, was reviewed. The binder indicated there was no infection surveillance completed for the month of June 2024. The IPN stated she got behind on

the month of June 2024 and had to catch up. The IPN stated she was responsible for keeping up with the infection surveillance every day to be aware of what was going on in the facility. The IPN stated falling behind on the infection surveillance had the potential be to be unaware of a resident having symptoms of an infection and could delay informing the resident's physician, which would cause a delay in treatment.

During an interview on 6/27/2024 at 11:21 a.m., with the Director of Nursing (DON), the DON stated the IPN was responsible for updating her infection surveillance documentation daily to see if a resident was having any new signs and symptoms of an infection. The DON stated keeping updated on the infection surveillance protected the residents from the spread of possible infection so they could address the infection right away with a treatment plan. The DON stated keeping up with the infection surveillance allowed the facility to see any trends of infection and to address the issue quickly before it worsened.

A review of the facility's policy and procedure (P&P) titled, Infection Control Program, undated, indicated, the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 47679 potential for actual harm Based on interview and record review, the facility failed to maintain complete antibiotic stewardship Residents Affected - Many documentation for the facility for June 2024.

This deficient practice had the potential for residents to be administered and prescribed antibiotics (medication to treat infections) inappropriately and unnecessarily.

Findings:

During a concurrent interview and record review on 6/25/2024 at 9:46 a.m., with the Infection Preventionist Nurse (IPN), the facility's Antibiotic Stewardship Binder, dated 2024, was reviewed. The binder indicated there was no antibiotic stewardship documentation completed for the month of June 2024. The IPN stated

she got behind on the month of June 2024 and had to catch up. The IPN stated she was responsible for keeping up with the antibiotic stewardship every day to keep track of the residents who were taking antibiotics. The IPN stated falling behind on the antibiotic stewardship had the potential for residents to be given antibiotics and would not be followed up to ensure the antibiotics were appropriate and necessary to treat the infection.

During an interview on 6/27/2024 at 11:23 a.m., with the Director of Nursing (DON), the DON stated the IPN was responsible for keeping up with the antibiotic stewardship documentation. The DON stated keeping up with the antibiotic stewardship ensured the communication between the nurses and the residents' physician to ensure the residents receive the necessary treatment for their infection. The DON stated by not keeping up with the antibiotic stewardship, the residents could potentially be given unnecessary antibiotics and their infection could become worse.

A review of the facility's policy and procedure (P&P) titled, Infection Control Program, undated, indicated,

The facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679 potential for actual harm Based on interview and record review, the facility failed to offer and administer the pneumococcal vaccine Residents Affected - Some (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames

the air sacs in one or both lungs]) to four of five sampled residents (Resident 54, 60, 62, and 70), who were eligible to receive the vaccine.

This deficient practice had the potential to result in the development and spread of pneumonia.

Findings:

a. A review of Resident 54's Admission Record (Face Sheet), indicated Resident 54 was initially admitted to

the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses that include but not limited to acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

A review of Resident 54's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 4/26/2024, indicated Resident 54 usually understood and was usually understood by others. The MDS indicated Resident 54's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 54 required moderate assistance (helper does less than half the effort by lifting, holding, or supporting) with eating, oral hygiene, toileting, showering, dressing, and personal hygiene.

A review of Resident 54's History and Physical (H&P), dated 11/7/2023, indicated Resident 54 was unable to make healthcare decisions.

A review of Resident 54's Medical Expenses Summary, dated 1/1/2018 through 12/31/2020, indicated Resident 54 was ordered the pneumococcal 13-valent conjugate vaccine (PCV 13, type of pneumococcal vaccine) on 11/11/2020.

During a concurrent interview and record review on 6/26/2024 at 11:22 a.m., with the Infection Preventionist Nurse (IPN), Resident 54's Immunization Record and the Centers for Disease Control and Prevention's (CDC) Pneumococcal Vaccine Timing for Adults, dated 3/15/2023, were reviewed. The Immunization Record indicated Resident 54 received the pneumococcal vaccine on 11/13/2020. The Pneumococcal Vaccine Timing for Adults indicated Adults [AGE] years and older who received only the PCV 13 at any age were eligible to receive the 20-valent pneumococcal conjugate vaccine (PCV20, type of pneumococcal vaccine)

after one year or the pneumococcal polysaccharide vaccine (PPV23, type of pneumococcal vaccine) after one year. The IPN stated Resident 54 had received only one dose of the pneumococcal vaccine on 11/13/2020 and per the CDC Pneumococcal Vaccine Timing for Adults chart, Resident 54 was eligible for another dose of the pneumococcal vaccine at least a year after. The IPN stated Resident 54 was eligible for

the PCV 20 or PPSV 23 and should have been offered and administered if Resident 54's responsible party (RP) provided consent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0883 b. A review of Resident 60's Admission Record (Face Sheet), indicated Resident 60 was initially admitted to

the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses that include but not limited to Level of Harm - Minimal harm or sepsis (a body's overwhelming and life-threatening response to infection), urinary tract infection (UTI, an potential for actual harm infection in any part of the urinary system), and acute kidney failure.

Residents Affected - Some A review of Resident 60's MDS, dated [DATE REDACTED], indicated Resident 60 was able to be understood by others and usually able to understand others. The MDS indicated Resident 60's cognition was severely impaired.

The MDS indicated Resident 60 required maximal assistance (helper does more than half the effort in lifting, holding, or providing support) with eating, toileting, showering, dressing, and personal hygiene.

A review of Resident 60's H&P, dated 4/17/2024, indicated Resident 60 could make needs known but could not make medical decisions.

During a concurrent interview and record review on 6/26/2024 at 11:20 a.m., with the IPN, Resident 60's Immunization Record and Pneumococcal Immunization Informed Consent were reviewed. The Immunization

Record did not indicate that Resident 60 had received any pneumococcal immunizations. The Pneumococcal Immunization Informed Consent indicated Resident 60's RP had consented for Resident 60 to receive the pneumococcal vaccine on 4/13/2023. The IPN stated there was no record of Resident 60 receiving any of

the pneumococcal vaccines in the past which made her eligible to receive any of the pneumococcal vaccines available. The IPN stated Resident 60 should have received the pneumococcal vaccine after her RP had consented for the administration.

c. A review of Resident 62's Admission Record (Face Sheet), indicated Resident 62 was initially admitted to

the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses that include but not limited to sepsis, urinary tract infection, and chronic kidney disease (longstanding disease of the kidneys leading to renal failure).

A review of Resident 62's MDS, dated [DATE REDACTED], indicated Resident 62 was usually able to understand and usually be understood by others. The MDS indicated Resident 62's cognition was severely impaired. The MDS indicated Resident 62 requires supervision with eating. The MDS indicated Resident 62 was dependent (helper does all the effort while the resident does none of the effort in completing the activity) on staff for toileting, bathing, and dressing.

A review of Resident 62's H&P, dated 8/22/2023, indicated Resident was able to make needs known but unable to make medical decisions.

During a concurrent interview and record review on 6/26/2024 at 11 a.m., with the IPN, Resident 62's Immunization Record was reviewed. The Immunization Record did not indicate that Resident 2 had received any pneumococcal immunizations. The IPN stated the Immunization Record did not indicate that Resident 62 had received any of the pneumococcal vaccines and based on his age, Resident 62 should have been offered any of the pneumococcal vaccines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0883 d. A review of Resident 70's Admission Record (Face Sheet), indicated Resident 70 was initially admitted to

the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] with diagnoses that include but not limited to Level of Harm - Minimal harm or metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood), chronic potential for actual harm obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear). Residents Affected - Some

A review of Resident 70's MDS, dated [DATE REDACTED], indicated Resident 70 was able to understand and be understood by others. The MDS indicated Resident 70's cognition was severely impaired. The MDS indicated Resident 70 required maximal assistance with eating, oral hygiene, toileting, showering, dressing, and personal hygiene.

A review of Resident 70's H&P, dated 5/7/2024, indicated Resident 70 could make needs known but could not make medical decisions.

A review of Resident 70's Medical Expenses Summary, dated 1/1/2018 through 12/31/2020, indicated Resident 70 was ordered PCV 13 on 11/17/2020.

During a concurrent interview and record review on 6/26/2024 at 11:24 a.m., with the IPN, Resident 70's Immunization Record and the CDC's Pneumococcal Vaccine Timing for Adults, dated 3/15/2023, were reviewed. The Immunization Record indicated Resident 70 received the pneumococcal vaccine on 12/10/2020. The Pneumococcal Vaccine Timing for Adults indicated Adults [AGE] years and older who received only the PCV 13 at any age were eligible to receive PCV20 after one year or PPV23 after one year.

The IPN stated Resident 70 had received only one dose of the pneumococcal vaccine on 12/10/2020 and per the CDC Pneumococcal Vaccine Timing for Adults chart, Resident 70 was eligible for another dose of the pneumococcal vaccine at least a year after. The IPN stated Resident 70 was eligible for PCV 20 or PPSV 23 and should have been offered and administered if Resident 70's responsible party (RP) provided consent.

During an interview on 6/26/2024 at 11:29 a.m., with the IPN, the IPN stated the purpose of administering the pneumococcal vaccine to the residents was to prevent the contraction and the spread of pneumococcal disease. The IPN stated without the protection of the vaccine, the residents were at risk of contracting pneumococcal disease which could severely affect their health and could cause death in the worst case.

During an interview on 6/27/2024 at 11:26 a.m., with the Director of Nursing (DON), the DON stated the facility based the resident's pneumococcal vaccine schedule on the CDC Pneumococcal Vaccine Timing for Adults. The DON stated they use this as a guide to determine which pneumococcal vaccine was appropriate for the resident. The DON stated the purpose of the vaccine was lessen the chance of contracting pneumonia and to lessen symptoms if they were to contract it. The DON stated the resident population were vulnerable to the disease and were at risk for their health to deteriorate (worsen). The DON stated residents who do not receive the pneumococcal vaccine on schedule were put at risk for contracting pneumonia, which could affect their health negatively and cause the resident to be hospitalized .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0883 A review of the facility's policy and procedure (P&P) titled, Immunizations: Influenza, Pneumococcal Vaccinations, dated 11/2017, indicated, Each resident is offered an influenza (October 1 through March 31 Level of Harm - Minimal harm or annually) and/or pneumococcal immunization in accordance with Center of Disease (CDC) guidelines, potential for actual harm unless the immunization is medically contraindicated, or the resident has already been immunized during the time periods indicated by CDC. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Minimal harm or potential for actual harm 47858

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 32 bedrooms (Rooms A, B, C, D).

This deficient practice could adversely affect the adequacy of space, nursing care, comfort, and privacy to

the residents and their visitors residing in Rooms A, B, C, and D.

Findings:

A review of the facility census, dated 6/24/2024, indicated Rooms A, B, C, and D had the capacity to accommodate six residents in the room.

A review of the facility's Client Accommodation Analysis (undated), indicated the following measurements for Rooms A, B, C, and D:

1. Rooms A and B measured 478.33 square feet ([sq. ft.]- unit of measurement).

2. Room C measured 487.44 sq. ft.

3. Room D measured 479.79 sq. ft.

During the initial tour of the facility, on 6/24/2024 at 10:07 a.m., it was observed Rooms A, B, C, and D were occupied by six residents in each room.

During observations made throughout the course of the survey, from 6/24/2024, to 6/27/2024,

there were no adverse effects that pertained to the adequacy of space, nursing care, comfort, and privacy of

the residents in rooms A, B, C, and D. The rooms had enough space for the resident's beds and

dressers.

During a concurrent record review and interview, on 6/27/2024, 7:40 a.m., with the Administrator (ADM), the facility's Room Waiver Request, dated 6/4/2024, was reviewed. The request indicated the facility normally admitted residents for behavior and psychological problems. The ADM stated that Rooms A, B, C, and D had six residents in each room. The ADM stated the facility would continue to request for a room waiver and in its requesting granting room variance, which will not adversely affect the residents' health and safety. The Department will recommend continuation of the request for a waiver/variance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47858

Residents Affected - Some Based on interview and record review, the facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents.

This deficient practice had the potential for inadequate space for each resident's privacy and unsafe nursing care.

Findings:

A review of the facility's Room Waiver Request letter, dated 6/4/2024, indicated the following two-person rooms did not meet the 80 square feet ([sq. ft.]- a unit of measurement) per resident requirement:

Room # # of beds Square Foot Per Room Square Foot Per Resident

room [ROOM NUMBER] 2 139.75 sq. ft. total 69.87 sq. ft.

room [ROOM NUMBER] 2 141.31 sq. ft. total 70.65 sq. ft.

room [ROOM NUMBER] 2 139.18 sq. ft. total 69.59 sq. ft.

room [ROOM NUMBER] 2 139.18 sq. ft. total 69.59 sq. ft.

room [ROOM NUMBER] 2 139.18 sq. ft. total 69.59 sq. ft.

room [ROOM NUMBER] 2 139.18 sq. ft. total 69.59 sq. ft.

room [ROOM NUMBER] 2 140.25 sq. ft. total 70.12 sq. ft.

room [ROOM NUMBER] 2 140.25 sq. ft. total 70.12 sq. ft.

During observations made throughout the course of the survey, from 6/24/2024 to 6/27/2024, there were no adverse effects that pertained to the residents' care provided by facility staff, residents' privacy, health, and safety related to the provided living space of less than 80 sq. ft. per resident.

During a concurrent record review and interview, on 6/27/2024 at 7:40 a.m., with the Administrator (ADM),

the facility's Room Waiver Request, dated 6/4/2024, was reviewed. The ADM stated that the rooms were a hair under the regulatory requirements and that the facility would ensure patient care and safety would not be compromised or effected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 65 555715

F-F867.

Findings:

During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the Director of Nursing (DON), the facility's QAPI Plan and Sign-In Sheet, dated 4/1/2024 to 4/30/2024, was reviewed. The plan indicated that the facility planned to improve immunizations, enhanced barrier precautions, and closed discharge charts. The sign in sheet did not include the IPN's name or signature. There were no documents that indicated an outline of specific interventions and there was no indication that progress was monitored.

During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the DON, the facility's QAPI Plan and Sign-In Sheet, dated 5/1/2024 to 5/31/2024, was reviewed. The plan indicated the facility planned to improve the Fall Prevention Program and Informed Consents. The plan indicated the Medical Records Department, and the Nursing Department would create a long to track when consents are obtained. There was no documentation provided to indicate a specific, measurable outcome. There was no documentation provided to indicate that progress was monitored. The facility was unable to provide a log that was created as indicated in the QAPI action plan. The sign-in sheet did not include the IPN's name or signature.

During a concurrent record review and interview, on 6/27/2024, at 2:22 p.m., with the Director of Nursing DON, the facility's QAPI Plan and Sign-In Sheet, dated 6/1/2024 to 6/30/2024, was reviewed. The QAPI Plan indicated the facility was to replace the facility's old roof. The sign in sheet did not include the IPN's name or signature. There were no documented minutes of the QAPI meeting. The DON stated that department heads usually talked about issues the facility had and they all work together to decide which issue or concern would be addressed that month.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0865 During an interview, on 6/27/2024, at 2:40 p.m., with the DON, the DON stated that the facility's QAPI meetings did not include the attendance of the Infection Prevention Nurse. The DON stated that the IPN Level of Harm - Minimal harm or informally relayed any issues to the DON that needed to be addressed but did not attend the QAPI meetings. potential for actual harm The DON stated that the facility did not have a method to routinely track and monitor patient safety concerns or issues. The DON stated that the current QAPI program was not effective because of the lack of data Residents Affected - Many collection to track the progress of the action plans set forth by the QAA Committee. The DON stated that there was a potential for the facility to not be able to solve the identified patient care issues.

A review of the facility's Policy and Procedure (P&P), titled QAPI (undated), indicated the facility was to monitor existing Quality Improvement and Quality Measures (QI/QM) results, internal monitors for fall, utilization of antipsychotic medications, infection control surveillance, safety, incident/accidents, and pharmacy. The policy also indicated the QAPI teams analyzed data regularly, monthly reports and graphs were published, logs were kept up to date, and minutes of all (QAPI) meetings were maintained.

A review of the facility's P&P, titled QAPI Compliance (undated), indicated the facility was to establish measurable outcomes focused criteria to use in their efforts at uncovering areas that may adversely impact

the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 65 555715 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555715 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 47858

Residents Affected - Many Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to implement measures to effectively collect and use data to monitor the effectiveness of Quality Assurance Plan Improvement (QAPI) plans and track overall performance for all 99 residents.

This deficient practice had the potential to negatively impact resident care, safety, and satisfaction, and had

the potential to allow facility-identified resident care issues or concerns to reoccur within the facility. Cross reference