Colonial Gardens Nursing Home

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

his arm. The DON stated notifying Physician 1 would have allowed Physician 1 to order for any medical or psychiatric evaluations and/or medications. The DON stated if Resident 5 were confused, a medical diagnosis such as an infection could have explained the sudden onset. The DON stated, without notifying Physician 1, the necessary evaluation and treatment were delayed. The DON stated in addition to notifying Physician 1, Conservator 1should have been notified to ensure he was aware of what was going on with Resident 1. The DON stated Conservator 1 was responsible for making any medical decisions for Resident 1 and may advocate for other assessments and/or treatments.During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.During a review of the facility's Performance Improvement Plan- Abuse Investigation and Reporting, initiated 7/1/2025, the Improvement Plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents and report any abuse allegations immediately to the three government agencies. The Improvement Plan indicated the licensed nurse would initiate the Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) and notify the primary physician and the resident and/or their responsible party.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

allegation on 9/9/2025. The DON stated per the facility's policy and recent in-services, LVN 11 should have reported the abuse allegation to the ADM who would then initiate an investigation. The DON stated Resident 5 did not specify who hit him, therefore, the alleged perpetrator could have been a staff member or another resident. The DON stated Resident 5's abuse allegation did not have many specifics and without

the proper reporting and investigation, Resident 5 and other residents were at risk for further abuse.During

an interview on 9/25/2025 at 8:58 a.m., with the ADM, the ADM stated he was the abuse coordinator in the facility, and he was responsible for investigating all abuse allegations brought to his attention. The ADM stated all staff members were responsible for notifying him of all abuse allegations and were instructed to notify CDPH, the ombudsman, and law enforcement to ensure all reports were completed within the two-hour window. The ADM stated once Resident 5 informed LVN 11 of being hit, LVN 11 had the responsibility of reporting, not only to him, but to the necessary agencies so an investigation could be initiated. The ADM stated ensuring proper reporting was essential to protecting the residents in the facility.During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 4/2024, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.During a review of the facility's Performance Improvement Plan- Abuse Investigation and Reporting, initiated 7/1/2025, the Improvement Plan indicated the root cause was communication when an incident happened. The Improvement Plan indicated the goal was for staff to inform the Administrator and the DON promptly about any incidents and report any abuse allegations immediately to the three government agencies. The Improvement Plan indicated to monitor this goal daily and monthly, and to track and trend the Change of Conditions for possible abuse allegations.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

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)

Federal health inspectors cited COLONIAL GARDENS NURSING HOME in PICO RIVERA, CA for a deficiency under regulatory tag F-F0656 during a complaint investigation conducted on 2025-11-14.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of COLONIAL GARDENS NURSING HOME.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-14.