Colonial Gardens Nursing Home

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 11, 2026.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 11, 2026.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 1, 2026.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 1, 2026.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 15, 2026.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 15, 2026.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 15, 2026.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 14, 2026.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 12, 2026.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 12, 2026.

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.

Rule F0726. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 28, 2025.

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.

Rule F0584. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 5, 2025.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 14, 2025.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 14, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 14, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 14, 2025.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 21, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 21, 2025.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 21, 2025.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 21, 2025.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Rule F0867. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 21, 2025.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 24, 2025.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 24, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 24, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 24, 2025.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Ensure that residents are fully informed and understand their health status, care and treatments.

Rule F0552. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies.

Rule F0628. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Assess the resident when there is a significant change in condition

Rule F0637. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

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.

Rule F0693. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Rule F0757. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

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.

Rule F0761. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

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.

Rule F0808. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Rule F0911. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Make sure that a working call system is available in each resident’s bathroom and bathing area.

Rule F0919. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Rule F0912. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Jun 21, 2025.

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.

Rule F0625. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 2, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 9, 2025.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 9, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 9, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 9, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 24, 2024.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Sep 23, 2024.

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Rule F0553. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 9, 2024.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 9, 2024.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 9, 2024.

Provide enough food/fluids to maintain a resident’s health.

Rule F0692. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 9, 2024.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 16, 2024.

Ensure that residents are fully informed and understand their health status, care and treatments.

Rule F0552. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Rule F0561. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Rule F0604. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Rule F0676. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Rule F0686. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

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.

Rule F0758. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure medication error rates are not 5 percent or greater.

Rule F0759. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure that residents are free from significant medication errors.

Rule F0760. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

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.

Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Rule F0805. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Have a plan that describes the process for conducting QAPI and QAA activities.

Rule F0865. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Rule F0867. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Implement a program that monitors antibiotic use.

Rule F0881. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Rule F0883. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Rule F0911. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Rule F0912. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Jul 26, 2024.