Casa Coloma Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure their abuse policy was operationalized and implemented properly to prohibit and prevent abuse (aggressive or violent behavior), ensure timely reporting, thorough investigation, and appropriate response to an allegation of resident-to-resident physical abuse when one of 32 sampled residents (Resident 2) report of being physically assaulted by another resident was not handled according to their policy and regulations when the facility staff were not aware of the reporting requirements of allegations of abuse. These failures had the potential for allegations of actual or suspected resident abuse to not be identified, reported and investigated placing residents' safety at risk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment, supervision, and equipment maintenance to ensure safety and prevent accidents for 3 of 32 sampled residents (Resident 164, Resident 7, and Resident 108) when: 1. Specimen collection tubes were left unsecured at Resident 164's bedside;2. The physician's order to apply and monitor padded side rails for Resident 7, who had a history of seizures (a condition in which abnormal electrical activity in the brain occurs causing changes in level of consciousness and jerking movements) was not implemented, and3. Resident 108's bed remote control cord had exposed frayed wires accessible to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medications (medications with high potential for abuse or addiction) for four of 32 sampled residents (Residents 32, Resident 27, Resident 21 and Resident 114) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) did not reconcile to indicate the medications were given to Residents 32, Resident 27, Resident 21, and Resident 114. This failure resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 7.69% error rate when three medication errors out of 39 opportunities were observed during a medication pass for two of four residents (Residents 98 and Resident 162). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.1a. During a medication pass observation on 4/22/26 starting at 7:53 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored safely, for a census of 131, when:Medication and medical supplies were available for residents' use past their expiration dates; and,Resident 63's topical cream was stored at bedside. These failures had the potential for residents to receive medications with decreased strength or effectiveness and for residents who have confusion to accidentally ingest medications kept at bedside. 1. During a concurrent observation and interview on 4/21/26 at 3:46 p.m. with the Assistant Director of Nursing (ADON), an inspection of Station 3 Medication Storage Room identified the following expired and discontinued medications and medical supplies: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize proper personal hygiene practices (e.g., proper hand washing and dish washing) to prevent contamination of food when:1. Hot water was not available in the kitchen handwashing sink;2. Certified Dietary Manager (CDM) picked up a piece of ice from the floor, then touched food thermometers without performing hand hygiene; and,3. Dietary staff were observed preparing to serve resident's drinks with reusable lids that were still wet. These failures had the potential to spread food-borne illness to all 131 residents of the facility. 1. During an observation on 4/21/26, at 8:02 a.m., in the facility kitchen, no hot water was available in the handwashing sink after allowing the hot water faucet to run for approximately 60 seconds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program for two of 32 sampled residents (Resident 99 and Resident 89) when: There was no Enhanced Barrier Precaution (EBP- an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of carrying multidrug-resistant organisms or MDRO) sign posted for Resident 99. There was no adequate Personal Protective Equipment (PPE) used by staff during Resident 89's care. These failures increased the risk for Resident 99 and Resident 89 to be exposed to infections that are hard to treat. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a POLST (Physician Orders for Life-Sustaining Treatment-a medical order from physician that specifies what type of medical treatment a person wants during serious illness) that accurately reflects resident's wishes for 2 of 32 sampled residents (Resident 13 and Resident 19) when: 1. Resident 19's POLST in clinical record did not indicate the same treatment as the physician's order; and, 2. Resident 13's code status (a status indicating what should be done if the resident had no pulse and not breathing) indicated on Residents 13's physician order did not match Resident 13's POLST. These failures had the potential for Resident 13 and Resident 19 to receive treatment that did not follow their wishes. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that allegation involving verbal and physical abuse (aggressive or violent behavior toward other) was identified, thoroughly investigated and reported to the appropriate agencies for one of 32 sampled residents (Resident 2), when Resident 2 reported that she was hit by Resident 31 and there was no documented evidence that the investigation and reporting were completed. This failure had the potential to place Resident 2 and other residents at risk for abuse and mistreatment and prevented timely investigations by oversight agencies. A review of the admission record indicated the facility admitted Resident 2 in 2024 with multiple diagnoses which included heart disease and polyarthritis (inflammation, pain and stiffness of multiple joints). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received necessary services to maintain personal hygiene for one of 32 sampled residents (Resident 7), when showers or bed bath were not provided two times a week as scheduled. This failure affected Resident 7's dignity, self-esteem, and had the potential to affect resident's overall well-being. A review of the admission record indicated the facility admitted Resident 7 earlier this year with multiple diagnoses which included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following stroke affecting left side. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter (a thin flexible tube to drain urine) care in a manner to prevent catheter related infections for 1 of 32 sampled residents (Resident 161) when Resident 161's urinary (catheter placed into bladder) drainage bag and nephrostomy (catheter inserted into the kidney) drainage bag were laying on the floor in the same privacy bag. This failure had the potential to result in urinary tract infections for Resident 161. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standard of practice when:The oxygen order was not followed for Resident 135;The oxygen tubing was not labeled, and oxygen in use signage was not in place for Resident 52 and,The oxygen titration order was not followed for Resident 121. These failures had the potential for Resident 135, Resident 121, and Resident 52 to experience respiratory distress, and an increased risk for fire hazards for Resident 52. 1. A review of the admission Record indicated Resident 135 was admitted [DATE] with diagnoses including asthma (chronic lung disease causing airways to become inflamed, narrow, making it hard to breathe) and obstructive sleep apnea (brief episodes of stopped breathing or restricted airflow reduce blood oxygen). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management in accordance with professional standards and resident centered care plan for one of 32 sampled residents (Resident 74), when facility did not assess Resident 74's pain, did not offer non-pharmacological (strategies that do not involve use of pain medications) interventions, and did not offer pain medications. This failure had the potential for Resident 74 to be in pain and have ineffective pain management. A review of the admission record indicated the facility admitted Resident 74 in 2017 with multiple diagnoses which included osteoarthritis (pain, stiffness, and swelling of multiple joints) and inflammatory radiculopathy of lower back (pinched nerve, causing pain that goes down the leg (s). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services in accordance with physician order, plan of care, and assessment for one of 32 sampled residents (Resident 74), when the right sided bed rail utilized for Resident 74's bed was not correctly sized. This failure had the potential to affect Resident 74's safety. A review of the admission record indicated the facility admitted Resident 74 in 2017 with multiple diagnoses which included cognitive impairment, weakness, and history of falling. A review of Order Summary report for Resident 74 contained a physician order dated 1/4/26 which indicated, Side rails 1/4 [quarter size] x 2 for bed mobility (turning and repositioning). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one of 32 sampled residents (Resident 162) when Resident 162's Insulin Glargine (a long-acting type of insulin - a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered as scheduled per physician's order. This failure had the potential to result in uncontrolled blood sugar for Resident 162 and placed Resident 162 at risk for developing signs and symptoms of high blood sugar. During a review of Resident 162's admission records, the records indicated Resident 162 was admitted to the facility in April 2026 with diagnosis that included Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow prescribed therapeutic diets (Physician prescribed meal plans that modify nutrient, calorie, or texture intake to treat medical conditions, and manage chronic diseases) for three residents (Resident 95, Resident 99, and Resident 134), for a census of 131. These failures had the potential for negative health outcomes for Resident 95, Resident 99, and Resident 134. During an observation in the facility kitchen on 4/22/26, at 12:05 p.m., Resident 99's food tray ticket was observed to read Diet: 2gm [gram, unit of measure] Sodium. Kitchen staff prepared Resident 99's lunch meal. Kitchen staff prepared the regular entree item country fried steak for Resident 99, and placed the tray on the food cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was uninterrupted power supply for life sustaining equipment during a power outage, for a census of 131. This failure had the potential for vulnerable residents to experience life threatening situation during power interruptions. During an observation on 4/23/26 starting at 1:14 p.m., the facility had a power interruption. The facility staff were observed taking out extension cords and they were checking residents with oxygen concentrators and those with air mattress. The staff brought out flashlights and power cords to plug into the red emergency outlets to power the oxygen concentrators in Station 2. The staff stated the outlets were not working and they needed oxygen tanks. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure 32 resident rooms (rooms 21, 22, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 42, 43, 44, 45, 46, 47, 48, 49, 53, 55, 56, 57, 58, and 59) met the required 80 square feet (sq. ft.) per resident. This failure had the potential for residents residing in these rooms to not have enough space for the provision of care and lack of privacy. The ADM provided the room measurements for 32 rooms with three residents. The room measurements for each room were as follows:room [ROOM NUMBER] at 218.4 with 72.8 sq. ft. per residentroom [ROOM NUMBER] at 218.4 with 72.8 sq. ft. per residentroom [ROOM NUMBER] at 218.4 with 72.8 sq. ft. per residentroom [ROOM NUMBER] at 218.4 with 72.8 sq. ft. per residentroom [ROOM NUMBER] at 218.4 with 72.8 sq. ft. per residentroom [ROOM NUMBER] at 218.4 with 72.8 sq. ft. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when: 1. Licensed Nurse 7 (LN 7) disposed tramadol (a controlled substance medication to treat pain without another LN to cosign the destruction; 2. Two out of five medication cart-controlled drug sign-in/sign-out sheets (sheets used to reconcile inventory of controlled medications in the medication cart by the outgoing and the incoming LN during a shift change) did not have signatures of the outgoing and the incoming nursing shift; and 3. The DON and pharmacist did not document destruction of controlled medications in accordance with facility policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility had an 8.82% error rate when three medication errors out of 34 opportunities were observed during a medication pass for two of four Residents (Residents 101 and 138). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multi-dose medications were dated with an open and discard date to ensure they were not used beyond the discard date. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety when: 1. One container of prepared apple juice and one container of iced tea concentrate were found expired in the walk-in refrigerator. 2. A box soaked with cooking oil was found in the dry food storage area of the kitchen. 3. Cracked light cover found overhead in between the steam table and food prep area. Missing light covers found in the dry storage area. 4. No air gaps were found on the food production sink, the three compartment sink, and the large sink next to the dishwasher. These failures had the potential to result in food contamination which could cause illness in medically vulnerable residents who received and consumed food from the facility kitchen for a census 130.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. The facility did not implement proper infection control for two of 33 sampled residents (Resident 85 and Resident 301) when staff entered rooms of residents on droplet precautions without donning proper PPE (personal protective equipment- equipment worn to minimize exposure to infection); 2. The facility did not offer six out of 33 sampled residents (Resident 108, Resident 35, Resident 3, Resident 48, Resident 16, and Resident 110) to wash or sanitize their hands before meals; 3. Enteral feeding (providing nutrition) through a gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) equipments were not labeled and changed as scheduled. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 out of 33 sampled residents (Resident 3, Resident 108, Resident 137, Resident 20, and Resident 110) were provided with hot water in the bathroom sinks. In addition, the entire Hall 30's which housed 24 residents had no hot water in bathroom sinks when the heater pump was turned off for over 20 days period. This failure resulted in multiple residents not having comfortable water to wash their hands and faces and negatively impacted their physical wellbeing, and had the potential to result in delayed provision of care.

Inspectors wroteBased on observation, interview, and records review, the facility failed to ensure staff answered call lights (devices used by residents to signal his or her need for assistance from staff) in a timely manner for two of 33 sampled residents (Resident 108 and Resident 3). In addition, the dedicated call system at nursing station 1, which was designed to facilitate communication between residents and staff, was muted. These failures had the potential to result in the resident's requests and care needs not being met jeopardizing the health and safety of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were appropriate and followed as ordered for two of 33 sampled residents (Resident 94 and Resident 37) and failed to ensure Resident 109 took all the medications, when: 1. Resident 94 had conflicting orders for a knee brace, and 2. Resident 94 had order for oxygen that was not followed, and 3. Resident 37 had orders for monitoring for a medication that was no longer ordered. 4. Loose pills in a medication cup were observed at the bedside of Resident 109. These failures had the potential for Resident 94, Resident 37 and Resident 109 to receive care and treatment that was contradictory to the physician's orders leading to adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services were provided to one of 33 sampled residents (Resident 87) when Resident 87 was not assisted in the repair or daily use of their hearing aids. This failure had the potential to cause Resident 87 psychosocial harm by making him frustrated and angry due to his inability to hear clearly and communicate properly with staff, other residents, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one of 33 sampled residents (Resident 78), who had tube feeding (TF, a medical device surgically implanted into the stomach, so the person who can not eat normally due to swallowing problems can receive liquid nutrition), when the facility did not follow the physician's order to keep Resident 78's head of bed (HOB) elevated at 30 degrees during administration of nutrition through the TF on multiple occasions. This failure had the potential for Resident 78 to experience aspiration (inhalation of TF formula) and develop aspiration pneumonia (a lung infection that develops after the person inhales food or liquids into their lungs where the bacteria will grow and cause an infection) which could lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 33 sampled residents (Resident 78 and Resident 93) received oxygen therapy as prescribed by the residents' physicians, when Resident 78 and Resident 93 received oxygen at a higher rate than ordered. These failures had the potential to contribute to residents' discomfort and decreased ability to breathe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 47 was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 47 received psychotropic medication without implementation of non-pharmacological (non-drug) interventions and inadequate indication for use. This failure resulted in unnecessary medication for the resident, which had the potential for exposure to unwanted side effects associated with psychotropic medications such as sedation, falls, abnormal involuntary movements, and memory loss and increased risk of death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative services were provided for one of 33 sampled residents (Resident 15) when Restorative Nursing Services (RNS - nursing interventions that help people maintain or improve a resident's physical, mental, and emotional well-being.) were not initiated. This failure resulted in Resident 15 failing to maintain the highest practicable level of physical, functional, and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 33 sampled residents (Resident 117) with an accessible call light, when Resident 117's call light was bundled up and attached to the call light plate out of Resident 117's reach. This failure resulted in Resident 117 not able to call for assistance for care needs causing an increased risk for falls.

Inspectors wroteBased on observation and interview, the facility failed to ensure 32 resident rooms (rooms 21-29, 31-38, 40, 42-49, 53, 55-59) met the required 80 square feet (sq. ft.) per resident. This failure had the potential to result in inadequate space for the provision of care and decreased quality of life for residents residing in these rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure services for one of four sampled residents (Resident 1) when medication was administered by a Certified Nursing Assistant (CNA 1) to Resident 1 (RES 1). This failure had the potential for harm when staff who are not trained to administer medications, administered medication outside of their scope of practice and job duties, which could cause medication errors.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe and functional living environment for when two of four sampled residents (Resident 1 & Resident 3) had sliding glass doors in their rooms that were not able to be locked. This failure had the potential for people to enter the room from outside of the building and resulted in Resident 1 feeling unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one out of a census of 112 when the Certified Nursing Assistant 1 (CNA 1) did not use gloves when handling soiled linen, and did not use proper hand hygiene practices when handling clean linen after touching soiled linen. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments according to physician orders for one of three sampled residents (Resident 1) when Resident 1 was not given multiple treatment medications as ordered by the physician in November 2023, December 2023, and January 2024. This failure increased the resident's potential to have unmet health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 118 when the medication cart and treatment cart were left unlocked and unattended. These failures had the potential for medication misuse and drug diversion.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) Level 1 screening for 1 (Resident #56) of 4 sampled residents reviewed for PASARR.

Inspectors wroteBased on observation, interviews, record review, and review of a facility policy, the facility failed to ensure a resident's care plan was revised to include contact precautions for clostridium difficile (C-diff) for 1 (Resident #78) of 8 sampled residents reviewed for infection control.

Inspectors wroteBased on observations, interviews, record reviews, facility policy reviews, and document review, the facility failed to ensure staff wore personal protective equipment (PPE) when they provided care for 2 (Resident #40 and Resident #78) of 8 sampled residents reviewed for infection control. The facility also failed to ensure fit testing for 3 (Licensed Vocational Nuse #3, Registered Nurse #4, and Certified Nursing Assistant #5) of 4 staff reviewed for fit testing.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and procedure when abuse, dementia and resident's rights trainings including reference checks were not completed for one of 6 employees (Certified Nursing Assistant, CNA 1) prior to being assigned to provide care to residents. This failure placed the residents at risk for abuse, neglect and mistreatment. Additionally, the failure to provide CNA 1 with abuse prevention and reporting training denied her the ability to recognize incidents of abuse and the process for reporting such incidences.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he left the facility unaccompanied and without staff knowledge and wandered 3 buildings away from the facility that is located next to a busy cross street. This failure placed Resident 1 at high risk for being hit by a moving vehicle, falls, and potentially endangered his life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the nutritional status was maintained and monitored accurately for one of three sampled residents (Resident 1) when: Restorative Nursing Assistants (RNA) weighed Resident 1 with NPWT (negative pressure wound therapy, also known as a wound vac, a device to aid in wound healing) device connected to Resident 1, and Certified Nursing Assistants (CNAs) did not document Resident 1's meal intakes 3 times daily in a consistent manner, and Resident 1's preference to have a pureed diet (diet that consists of soft smooth foods) was not honored in a consistent manner. [...]

Inspectors wroteBased on interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice for one of 6 sampled residents (Resident 1) when: 1. Resident 1 did not receive a TSLO brace (thoracolumbosacralorthosis - a brace for the mid to lower back used to provide support after back injury) as ordered by the physician on admission, and 2. Results for Resident 1's CBC (complete blood count, measures white and red blood cells and platelet count) lab ordered stat (needs to be performed immediately) were not obtained and reported timely. These failures had the potential to negatively affect the health, safety, and medical condition of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from loss of personal property when facility policies were not in place to protect personal property from loss. This failure resulted in Resident 1's dentures, glasses, and hearing aids to be missing which had the potential for Resident 1 to have decreased communication and functioning.