Colonial Gardens Nursing Home
COLONIAL GARDENS NURSING HOME in PICO RIVERA, CA — inspection on June 27, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
555715
Form Approved OMB
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
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.
555715
Form Approved OMB
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