CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Colonial Gardens Nursing Home
View the most recent health deficiencies and inspection results for Colonial Gardens Nursing Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Colonial Gardens Nursing Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2026-04-02 | 2026-05-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-04-02 | 2026-05-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-03-16 | 2026-04-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2026-03-16 | 2026-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-03-16 | 2026-04-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-02-18 | 2026-03-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-12-30 | 2026-01-12 | Y |
| 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. | Health | 2025-12-30 | 2026-01-12 | Y |
| 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. | Health | 2025-12-04 | 2025-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-11-14 | 2025-12-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-11-14 | 2025-12-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-11-14 | 2025-12-14 | Y |
| 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. | Health | 2025-11-18 | 2025-12-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-15 | 2025-09-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-08-06 | 2025-08-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-08-06 | 2025-08-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-08-06 | 2025-08-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-08-06 | 2025-08-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-08-06 | 2025-08-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-06-24 | 2025-07-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-06-24 | 2025-07-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-06-24 | 2025-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-24 | 2025-07-24 | Y |
| 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. | Health | 2025-05-22 | 2025-06-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-05-22 | 2025-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-05-22 | 2025-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-05-22 | 2025-06-21 | N |
| 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. | Health | 2025-05-22 | 2025-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-05-22 | 2025-06-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-05-22 | 2025-06-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2025-05-22 | 2025-06-21 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-05-22 | 2025-06-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-05-22 | 2025-06-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-05-22 | 2025-06-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-05-22 | 2025-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-05-22 | 2025-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-05-22 | 2025-06-21 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2025-05-22 | 2025-06-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2025-05-22 | 2025-06-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2025-05-22 | 2025-06-21 | N |
| 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. | Health | 2025-05-22 | 2025-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-05-22 | 2025-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-05-22 | 2025-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-05-22 | 2025-06-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-05-22 | 2025-06-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2025-05-22 | 2025-06-16 | N |
| 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. | Health | 2025-04-16 | 2025-05-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-04-02 | 2025-05-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-10 | 2025-04-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-03-10 | 2025-04-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-10 | 2025-04-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-10 | 2025-04-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-11-18 | 2024-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-13 | 2024-09-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-21 | 2024-09-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-21 | 2024-09-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-21 | 2024-09-09 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-08-21 | 2024-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-05 | 2024-08-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-27 | 2024-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-27 | 2024-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-27 | 2024-07-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-27 | 2024-07-26 | N |
| 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. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-27 | 2024-07-26 | N |
| 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. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-06-27 | 2024-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-27 | 2024-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-27 | 2024-07-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-27 | 2024-07-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-27 | 2024-07-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-06-27 | 2024-07-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-27 | 2024-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-06-27 | 2024-07-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-06-27 | 2024-07-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-09-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-21 | 2023-07-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-08 | 2022-05-20 | N |
| Post nurse staffing information every day. | Health | 2022-04-08 | 2022-05-20 | N |
| 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. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-20 | N |
| 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. | Health | 2022-04-08 | 2022-05-20 | N |
| 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. | Health | 2022-04-08 | 2022-05-20 | N |
| 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. | Health | 2022-04-08 | 2022-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-05-20 | N |
| 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. | Health | 2022-04-08 | 2022-05-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-08 | 2022-05-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-08 | 2022-05-20 | N |
| 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. | Health | 2022-04-08 | 2022-05-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-08 | 2022-05-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-08 | 2022-05-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-08 | 2022-05-20 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-08 | 2022-05-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-08 | 2022-04-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-08 | 2022-04-28 | N |