All citations for Colonial Gardens Nursing Home
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
May 22, 2025
Showing 1 to 25 of 124 citations
Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (September 23, 2024).
Harm to a resident
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
The home gave a date the problem would be corrected (May 20, 2022).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (June 21, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (June 21, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (June 16, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Have a plan that describes the process for conducting QAPI and QAA activities.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Implement a program that monitors antibiotic use.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
The home gave a date the problem would be corrected (May 20, 2022).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (May 20, 2022).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (May 20, 2022).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (May 20, 2022).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
The home gave a date the problem would be corrected (April 28, 2022).
No harm, with potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
The home gave a date the problem would be corrected (June 21, 2025).
No harm, with potential for more than minimal harm
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
A waiver was granted (June 21, 2025).
No harm, with potential for more than minimal harm
Ensure proper usage of power strips and extension cords.
The home gave a date the problem would be corrected (June 16, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (November 24, 2024).
No harm, with potential for more than minimal harm
Ensure that residents are fully informed and understand their health status, care and treatments.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Ensure medication error rates are not 5 percent or greater.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
The home gave a date the problem would be corrected (July 26, 2024).
No harm, with potential for more than minimal harm
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
The home gave a date the problem would be corrected (July 26, 2024).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.