Colonial Care Center: 22% Weight Loss Goes Unnoticed - CA
Resident 188 entered the facility on December 6, 2024, weighing 119 pounds. He had non-Hodgkin lymphoma, muscle wasting, multiple pressure ulcers, and received nutrition through a feeding tube. By February 6, 2025, he weighed 93.2 pounds — a 22% weight loss that staff called "significant" but had largely ignored.
The resident told inspectors his legs "looked like bones" and pulled back his bed sheets to show how thin they had become. He said he hoped to gain weight after passing a swallow evaluation so he could eat some food along with his tube feeding. "I want to be stronger to participate in therapy," he said.
His weight dropped steadily from admission. By December 11, he was down to 115 pounds. A week later: 112 pounds. By December 27: 110 pounds. Each weigh-in showed continued loss, but nursing staff took no action.
The facility's registered dietitian didn't learn about the weight loss until January 7, 2025 — a month after admission — when she reviewed a weight report showing Resident 188 had lost nine pounds. She noted his ideal body weight range was 117 to 143 pounds and called the nine-pound loss "significant."
The dietitian tried to increase his tube feeding from 45 cubic centimeters per hour to 55, but the resident was having diarrhea. She held off on the increase and said she would reassess "as needed." She never did.
By January 31, nursing assistant RNA 1 weighed the resident and found he had dropped to 95 pounds — but she didn't document it in his medical record. Instead, she told Registered Nurse RN 3 verbally about the "lot of weight" he had lost.
"It is all in here," RNA 1 told inspectors, pointing to her head when asked for documentation of the 95-pound weight.
RN 3 said she didn't notify the physician because she was admitting another resident and "assumed Resident 188 would start gaining weight now that he was able to eat by mouth and was continuing to receive tube feeding."
The resident's diarrhea had stopped by mid-January, but no one increased his tube feeding or reassessed his nutritional needs.
Nobody created a change-of-condition report. Nobody called his doctor. Nobody told his family how much weight he had lost.
When inspectors weighed Resident 188 on February 6, he was down to 93.2 pounds. The facility's dietitian finally documented his condition that day, noting he had lost 17 pounds in the past month and 26 pounds since admission. She called it "significant" weight loss likely related to pressure ulcer healing, diarrhea, and respiratory failure.
Only then did staff notify the physician and family.
The resident's family member told inspectors that nursing staff had mentioned "in passing" that he was losing weight, but "no one informed her how much weight." When a nurse finally called on February 7 about his weight loss, they still didn't specify the actual amount lost.
"Now she was feeling worried about Resident 188's health," the family member said.
The facility's physician said he should have been notified immediately. "It was important he was notified so he could decide on new interventions and ensure the RD was assessing the resident's nutritional needs," MD 1 told inspectors.
The Assistant Director of Nursing said the weight loss was "outside of Resident 188's baseline" and should have triggered a change-of-condition report. He said the interdisciplinary team should have met to discuss new interventions and solutions.
"Based on Resident 188's current weight of 93.2 lbs., the interventions were not working and the IDT meeting should have been conducted to address the resident's progressive weight loss," the assistant director said.
The registered dietitian admitted she hadn't attended team meetings for weight loss and acknowledged that undocumented discussions meant nothing. "If it was not documented, it was not done," she said.
She also revealed she had based her assessments entirely on chart reviews and nurse reports — she never actually spoke to the resident himself.
The Director of Nursing said staff "cannot assume a weight loss was expected based on the resident's diagnosis" and must closely monitor weight trends through weekly weighings. She said she wasn't made aware of the severe weight loss and it was never discussed in team meetings.
The medical director said any significant weight changes needed immediate attention. "Continued weight loss was not good and affected a resident's well-being, could lead to malnutrition and slow pressure sore healing," MD 2 told inspectors.
The facility's own policies required notification of the dietitian in writing for any weight change of 5% or more. Weight loss of 5% in one month was considered significant; anything greater was severe. The policies also required notifying physicians and family within 24 hours of significant condition changes.
Resident 188's 7.6% weight loss in his first month qualified as severe under the facility's standards. His 22% loss over two months was catastrophic.
The Director of Staff Development said weights should be documented immediately after being taken. "We are all human and the RNAs could forget a weight or mix up the weights of different residents if they did not write them down right away," she explained.
RNA 1's failure to document the January 31 weight of 95 pounds meant the facility had no official record of the resident's condition for nearly a week, during which he lost another two pounds.
Federal inspectors also found problems with feeding tube management at the facility. They observed tubes left connected to residents when feedings were complete and tube feeding formula hanging for more than 48 hours when manufacturer guidelines called for replacement after 24 hours.
The violations placed residents at risk for infection and gastrointestinal problems, inspectors noted.
For Resident 188, the cascade of failures — from undocumented weights to missed notifications to absent reassessments — meant two months of steady decline while staff who could have intervened remained unaware or took no action.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COLONIAL CARE CENTER in LONG BEACH, CA was cited for violations during a health inspection on February 6, 2025.
Resident 188 entered the facility on December 6, 2024, weighing 119 pounds.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.