Casa Coloma Health Care Center

In the surveyor’s words

From the most serious findings on record at Casa Coloma Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 1, 2022

  Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was admitted to the facility with an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine; it is held in the bladder by a water-filled balloon, which prevents it from falling out) received assessment and interventions to treat the resident's inability to excrete urine according to the facility's policy regarding urinary catheter care and as indicated in Resident 1's physician order, dated 4/23/22. […]

• Actual harm, isolatedF726Dec 1, 2022

  Based on observation, interview and record review, the facility failed to ensure that nursing staff possessed the competencies and skills necessary to meet residents' needs safely and in a manner which enhanced health, safety, and psychological well-being for one of three sampled residents (Resident 1) when, nursing staff improperly inserted a urinary catheter (a flexible tube inserted into the bladder to drain urine; it is held in the bladder by a water-filled balloon, which prevents it falling out). This failure caused injury to Resident 1's urethra (a tube through which urine leaves the body) and resulted in Resident 1's experiencing unnecessary pain and heavy bleeding, and transfer to the Emergency Drpartment (ED). […]

• Actual harm, isolatedF600Nov 16, 2022

  Based on interview and record review, the facility neglected to provide supervision and monitoring to assure 1 of five sampled residents (Resident 1) was free from injury when Resident 1 suffered an open fracture of the femur (when broken thigh bone protruded through the skin at her left knee), and the facility was unable to determine the cause of injury. This failure resulted in Resident 1's admission to the acute care hospital and surgical repair of the broken thigh bone. Findings: A review of Resident 1's Face Sheet indicated she was readmitted to the facility in April 2022 with diagnoses including unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF812Jul 14, 2023

  Based on observation, interview, and record review, the facility failed to maintain the kitchen in sanitary condition for a census of 118 when the preparation (prep) area sink was leaking underneath the drain and the leak was seeping through the wall of the food storage room, and there were dirty broken floor tiles in the food storage room. These failures increased the potential to result in food contamination and foodborne illness to vulnerable residents receiving food from the facility kitchen. Findings: During a kitchen tour on 7/7/23 at 10:05 a.m., accompanied by the Dietary Manager (DM), 2 metal pans were observed underneath the prep area sink. One metal pan underneath the prep area sink drainpipe was observed to be halfway full of yellowish liquid. […]

• No harm, potential for more than minimal, patternF607Apr 24, 2026

  Based 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.A review of the facility's policy titled, Abuse… […]