ElderGrade

Inspection citations at Colonial Gardens Nursing Home

107 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 6 0
2025 41 0
2024 34 1
2023 1 0
2022 25 1
D April 2, 2026 Tag F0842 Complaint investigation Corrected May 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D April 2, 2026 Tag F0657 Complaint investigation Corrected May 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D March 16, 2026 Tag F0656 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D March 16, 2026 Tag F0641 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D March 16, 2026 Tag F0609 Complaint investigation Corrected Apr 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D February 18, 2026 Tag F0658 Complaint investigation Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D December 30, 2025 Tag F0761 Complaint investigation Corrected Jan 2026

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D December 30, 2025 Tag F0656 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D December 4, 2025 Tag F0726 Complaint investigation Corrected Dec 2025

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

D November 18, 2025 Tag F0584 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D November 14, 2025 Tag F0656 Complaint investigation Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D November 14, 2025 Tag F0609 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D November 14, 2025 Tag F0580 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D August 15, 2025 Tag F0656 Complaint investigation Corrected Sep 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D August 6, 2025 Tag F0867 Complaint investigation Corrected Aug 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

D August 6, 2025 Tag F0755 Complaint investigation Corrected Aug 2025

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D August 6, 2025 Tag F0657 Complaint investigation Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D August 6, 2025 Tag F0610 Complaint investigation Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D August 6, 2025 Tag F0609 Complaint investigation Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D June 24, 2025 Tag F0689 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D June 24, 2025 Tag F0610 Complaint investigation Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D June 24, 2025 Tag F0609 Complaint investigation Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D June 24, 2025 Tag F0580 Complaint investigation Corrected Jul 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

B May 22, 2025 Tag F0912 Corrected Jun 2025

Environmental Deficiencies

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

No actual harm, minimal potential

D May 22, 2025 Tag F0919 Corrected Jun 2025

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0880 Corrected Jun 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0808 Corrected Jun 2025

Nutrition and Dietary Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0757 Corrected Jun 2025

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0695 Corrected Jun 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0693 Corrected Jun 2025

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0656 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0641 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0637 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0628 Corrected Jun 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0558 Corrected Jun 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0552 Corrected Jun 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0550 Corrected Jun 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E May 22, 2025 Tag F0911 Corrected Jun 2025

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

E May 22, 2025 Tag F0755 Corrected Jun 2025

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

F May 22, 2025 Tag F0812 Corrected Jun 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.