COLONIAL GARDENS NURSING HOME
COLONIAL GARDENS NURSING HOME is a 99-bed nursing home in PICO RIVERA, California. CMS has certified it for Medicare and Medicaid since 1997-12-03. It averages 93.9 residents a day.
What harm was found in the violations cited at COLONIAL GARDENS NURSING HOME?
CMS lists 107 health-inspection deficiencies for COLONIAL GARDENS NURSING HOME since 2022-04-08, 82 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is J; the most recent health inspection was 2026-04-02.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-04-02 | F0657, F0842 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2026-03-16 | F0609, F0641, F0656 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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. | D |
| 2026-02-18 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D |
| 2025-12-30 | F0656, F0761 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / 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. | D |
| 2025-12-04 | F0726 | 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. | D |
| 2025-11-18 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D |
| 2025-11-14 | F0580, F0609, F0656 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D |
| 2025-08-15 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D |
| 2025-08-06 | F0609, F0610, F0657, F0755, F0867 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D |
| 2025-06-24 | F0580, F0609, F0610, F0689 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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. | D |
| 2025-05-22 | F0761, F0812 | 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. | F |
| 2025-05-22 | F0755, F0911 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | E |
| 2025-05-22 | F0550, F0552, F0558, F0628, F0637, F0641, F0656, F0693, F0695, F0757, F0808, F0880, F0919 | 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. / Ensure each resident’s drug regimen must be free from unnecessary 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. / Provide and implement an infection prevention and control program. / Make sure that a working call system is available in each resident's bathroom and bathing area. | D |
| 2025-05-22 | F0912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | B |
| 2025-04-16 | F0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D |
| 2025-04-02 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2025-03-10 | F0656, F0684, F0689, F0880 | 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, resident’s preferences and goals. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide and implement an infection prevention and control program. | D |
| 2024-11-18 | F0880 | Provide and implement an infection prevention and control program. | E |
| 2024-09-13 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J |
| 2024-08-21 | F0553, F0580, F0656, F0692 | 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. | D |
| 2024-08-05 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2024-06-27 | F0812, F0865, F0867, F0880, F0881 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Have a plan that describes the process for conducting QAPI and QAA activities. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. | F |
| 2024-06-27 | F0552, F0758, F0759, F0761, F0883, F0911 | Ensure that residents are fully informed and understand their health status, care and treatments. / 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. / 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. / 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. | E |
| 2024-06-27 | F0558, F0561, F0580, F0604, F0641, F0656, F0657, F0658, F0676, F0686, F0689, F0695, F0760, F0805, F0842 | 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. / Ensure that residents are free from significant medication errors. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2024-06-27 | F0912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | B |
| 2023-09-07 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D |
| 2022-04-08 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | G |
| 2022-04-08 | F0607, F0803, F0812, F0838 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. / 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. / Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | F |
| 2022-04-08 | F0578, F0609, F0610, F0656, F0684, F0686, F0689, F0726, F0755, F0758, F0761, F0867, F0880 | 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / 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, resident’s 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. / 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. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Provide and implement an infection prevention and control program. | E |
| 2022-04-08 | F0550, F0600, F0641, F0697, F0911 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Ensure each resident receives an accurate assessment. / Provide safe, appropriate pain management for a resident who requires such services. / Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | D |
| 2022-04-08 | F0732, F0912 | Post nurse staffing information every day. / Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | B |
Why was COLONIAL GARDENS NURSING HOME fined?
| Date | Type | Amount |
|---|---|---|
| 2024-08-05 | Fine | $36,700 |
How is COLONIAL GARDENS NURSING HOME staffed relative to the CA average?
| Measure | This facility | CA average |
|---|---|---|
| Total nurse staffing hours per resident per day | 4.24730 | 4.51570 |
| Total nursing staff turnover (%) | 36.6 | 36.7 |
| Average number of residents per day | 93.9 | 87.9 |
Who owns COLONIAL GARDENS NURSING HOME?
COLONIAL GARDENS NURSING HOME is registered with CMS as For profit - Limited Liability company, operates under the legal business name GARDENS HEALTHCARE LLC.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | AHM TRUST, LEHMANN, KENNETH | since 11/01/2024 |
| MANAGING CONTROL - GOVERNING BODY | STEPHENS, KENT | since 11/01/2024 |
| CORPORATE OFFICER | BAK, ABRAHAM, GASTWIRTH, MENACHEM | since 11/01/2024 |
| OPERATIONAL/MANAGERIAL CONTROL | STEPHENS, KENT, VICTORIA, XANTHE | since 11/01/2024 |
| ADP OF THE SNF | ABE AND RACHEL BAK FAMILY TRUST, BAK, ABRAHAM, GASTWIRTH, MENACHEM, LEHMANN, KENNETH, STEPHENS, KENT, VICTORIA, XANTHE | since 11/01/2024 |
Were you or a family member harmed at COLONIAL GARDENS NURSING HOME?