Health inspection·December 4, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA 1) had the competencies and skill sets necessary to immediately provide Basic Life Support ([BLS] medical care for residents experiencing cardiac arrest [when the heart stops beating] or respiratory distress [difficulty in breathing]) for one of three sampled residents (Resident 3), who had a full code status (when a medical personnel does everything possible to save a person's life in a medical emergency), was observed unresponsive in bed. This deficient practice had the potential for delayed provision of BLS for Resident 3 and other residents at risk of not receiving timely life saving measures. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included hypertension (high blood pressure) and heart failure (heart cannot pump enough blood and oxygen to meet the body's needs).During a review of Resident 3's History and Physical (H&P) dated [DATE], H&P indicated Resident 3 had the capacity to make medical decisions and was a full code status (when medical personnel does everything possible to save a person's life in a medical emergency). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 3 usually understood and was understood by others. The MDS indicated Resident 3 required supervision for eating, and upper dressing. The MDS indicated Resident 3 was dependent (helper does all the effort Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene and toileting hygiene. During a review of Resident 3's Progress Note dated [DATE] at 4:40 a.m., the Note indicated CNA 1 was checking on Resident 3's diaper and found Resident 3 unresponsive. The Notes indicated CNA 1 called Registered Nurse (RN 1) and RN 1 immediately assessed Resident 3 who was unresponsive, not breathing and pulseless. The Notes indicated RN 1 initiated Cardiopulmonary Resuscitation ([CPR] - an emergency procedure to restart a person's heart a person's heart and breathing after one or both suddenly stop. The note indicated the paramedics arrived at the facility at 4:10 a.m., after 911 was called and Resident 3 expired at 4:39 a.m. During a phone interview on [DATE] at 11:37 a.m., with CNA 1, CNA 1 stated on [DATE] at around 4:00 a.m., he went to Resident 3's room and noticed Resident 3 was not moving and walked out of the room to inform RN 1. CNA 1 stated RN 1 ran to the room and started CPR on Resident 1, while a Licensed Vocational Nurse (LVN) called 911, because RN 1 was shouting [from the room] to call 911. CNA 1 stated he had BLS training two months prior and during his BLS training, he was taught to initiate CPR as soon as he found someone unresponsive. CNA 1 stated, he left Resident 1 and did not check for Resident 1's pulse and breathing nor start CPR because at the facility, he was supposed to call the licensed nurse first. CNA 1 was unable to verbalize the process prior to initiating CPR. During a phone interview on [DATE] at 11:53 a.m., with RN 1, RN 1 stated on [DATE] at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555715 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Gardens Nursing Home 7246 S. Rosemead Blvd. Pico Rivera, CA 90660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)