Health inspection·December 30, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a care plan addressing a resident's diagnosis of sleep apnea (blocked airways) and use of a Bilevel Positive Airway Pressure ([BiPAP] a breathing therapy used to help a person with breathing difficulties) for one out of three sampled residents (Resident 2). These deficient practices had the potential to place Resident 2 at risk for device related injury, respiratory distress, and not receiving the necessary care and services. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 11/7/2025, the MDS indicated Resident 2's cognition (ability to think and process information) was intact. The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Summary Report, dated 12/30/2025, the order summary report indicated on 11/21/2025, Resident 2's attending physician prescribed the use of a BiPAP machine at bedtime for treatment of sleep apnea. During a concurrent observation and interview on 12/30/2025 at 8:00 a.m., in Resident 2's room, observed Resident 2's BiPAP machine on the nightstand next to the resident's bed. Resident 2 stated he used the BiPAP machine every night for sleep apnea. During a concurrent interview and record review on 12/30/2025 at 11:15 a.m., with the Assistant Director of Nursing (ADON), Resident 2's clinical health records including the document titled Psychiatric Evaluation and Mental Status Examination, dated 11/21/2025, Order Summary Report dated 12/30/2025, and the resident's active care plans, were reviewed. Resident 2's psychiatric evaluation included a diagnosis of sleep apnea. The order summary report indicated an active physician order dated 11/21/2025, for the use of the BiPAP machine nightly at bedtime to treat the resident's sleep apnea. Upon review of Resident 2's care plans, the ADON stated there was no care plan created or initiated to address Resident 2's sleep apnea. The ADON stated there was no care plan initiated for Resident 2's use of BiPAP. The ADON stated care planning serves as a communication tool among staff to ensure consistent implementation of goals and interventions, including monitoring of BiPAP use, resident education, and evaluation of tolerance. The ADON stated that without a care plan the staff would not know how to provide necessary care and services. The ADON stated this had the potential to place Resident 2 at risk for inconsistent use of the BiPAP machine and related complications, such as respiratory distress or injuries. During a review of the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the facility would develop and implement a comprehensive person-centered care plan which includes measurable objectives and (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 3 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 12/30/2025 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)