Compiled from official CMS federal data
COLONIAL GARDENS NURSING HOME, PICO RIVERA, CA — Violations & Inspection Reports
Does COLONIAL GARDENS NURSING HOME have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), COLONIAL GARDENS NURSING HOME (CCN 555715), in PICO RIVERA, CA, has federal inspection findings.
In its current inspection cycle, CMS cited the facility for 41 deficiencies; the most severe is rated F — which CMS classifies as "potential for harm," a level below actual harm (risk, but no harm confirmed). The latest standard health inspection on file is dated 2025-05-22. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $39,170 in civil money penalties on file against the facility. The record also includes 12 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Mar 2026). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 12 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Mar 2026.
- 6 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Jun 2025.
- 2 pressure-ulcer care citations (F686) — the consumer term is "bedsores"; most recent Jun 2024.
- 1 nutrition and hydration citation (F692) — the consumer terms are "malnutrition" and "dehydration"; most recent Aug 2024.
- 38 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
CMS has $39,170 in civil money penalties on file against this facility.
Below is this facility's federal inspection record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$39,170
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About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
57 more citations on file — Abuse & neglect 6 · Accidents & supervision 3 · Nutrition & hydration 1 · Medication & pharmacy 5 · Resident rights 8 · Other citations 29 (expand)
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure each resident receives an accurate assessment.
Ensure services provided by the nursing facility meet professional standards of quality.
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 a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide safe and appropriate respiratory care for a resident when needed.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Provide and implement an infection prevention and control program.
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.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure that residents are fully informed and understand their health status, care and treatments.
Reasonably accommodate the needs and preferences of each resident.
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 rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide and implement an infection prevention and control program.
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.
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide and implement an infection prevention and control program.
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.
Implement a program that monitors antibiotic use.
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.
Overall CMS star rating
This facility: 1 · CMS state average: 3.2
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Your federal record — tap to preview
Federal record
COLONIAL GARDENS NURSING HOME — Federal Record
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SECTION 7 — CASE CONTEXT
Add what you saw at COLONIAL GARDENS NURSING HOME to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?