Colonial Gardens Nursing Home

F 0656

timelines to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

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

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

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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

12/30/2025

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure the safe storage of medications for one of three sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for unsafe medication administration, misuse of medications and overdose. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE REDACTED]. Resident 2's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a

review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2025, the MDS indicated Resident 2's cognition (ability to think and process information) was intact. The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 12/30/2025 at 8:00 a.m., in Resident 2's room, with Resident 2, observed four prescription medications inside the nightstand next to Resident 2's bed, within reach and not secured. The medication bottles were not labeled for self-administration and were not stored in a locked medication card or secured drawer. Resident 2 stated, I take the medications every day whenever I want. The medication bottles included the following:a.

Atorvastatin (medication used to lower high cholesterol) 40 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one tablet daily.b. Torsemide (medication used to treat fluid retention) 20 mg, two tablets daily c. Fenofibrate (medication used to treat high cholesterol)160 mg, 1 tablet daily.d. Lisinopril (medication used to treat high blood pressure) 2.5 mg, one tablet daily. During interview on 12/30/2025 at 1:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility did not permit residents to keep medications at their bedside. The ADON stated the facility did not allow self-administration of medications unless there was a completed self-administration assessment, and a documented physician order. The ADON stated Resident 2 was assessed for self-administration of medication and was determined as not appropriate to self-administer medications. The ADON stated residents were not supposed to have medications in their rooms or take them on their own. The ADON stated that was not part of the facility policy or standard practice. The ADON stated the presence of multiple medications at Resident 2's bedside, and the resident's unsupervised administration, was unacceptable, unsafe, and should have been addressed by the nursing staff. The ADON stated unsecured access to antihypertensive and diuretics, such as lisinopril, and torsemide, placed Resident 2's at risk for overdose, dangerous drops in blood pressure or dehydration, adverse medications interactions or complications.

During a review of the facility's policy and procedure (P&P) titled Medication Labeling and Storage, revised 2023, the P&P indicated the facility would store all medications and biologicals in locked compartments.

The P&P indicated only authorized personnel would have access to keys. During a review of the facility's P&P titled Administering Medications', revised 4/2019, the P&P indicated medications would be administered in a safe and timely manner. The P&P indicated only persons licensed or permitted by the state to prepare, administer and document the administering of medications.

Event ID:

Facility ID:

If continuation sheet