LONG BEACH, CA - Federal inspectors cited Colonial Care Center for failing to notify physicians and family members when residents experienced significant health changes, including one case where a resident lost over 20% of their body weight without proper reporting.
Critical Communication Failures Documented
During a February 2025 inspection, surveyors found the 1913 E 5th Street facility failed to follow required notification protocols when Resident 188 experienced dramatic weight loss over a two-month period. The resident lost 9 pounds in January alone, representing a 7.6% weight loss, followed by an additional 15 pounds the following month.
By the end of the monitoring period, Resident 188 had lost 24 pounds total, representing a 20.1% weight loss over just 60 days. When inspectors weighed the resident during their visit, they documented an even more severe loss of 25.8 pounds, or 21.6% of the resident's body weight.
Federal regulations require nursing homes to immediately notify both the resident's physician and responsible family members when significant changes in condition occur. This notification system serves as a critical safety net, ensuring medical professionals can quickly assess and address potentially life-threatening situations.
Medical Significance of Rapid Weight Loss
Unintentional weight loss exceeding 5% of body weight within 30 days, or 10% within 180 days, is considered clinically significant in nursing home residents. Weight loss of this magnitude often indicates serious underlying medical conditions, medication side effects, swallowing difficulties, or inadequate nutrition.
When elderly residents experience rapid weight loss, immediate medical evaluation is essential to identify the underlying cause. Potential factors include infections, medication changes, depression, dental problems, or gastrointestinal disorders. Without prompt intervention, continued weight loss can lead to malnutrition, weakened immune function, increased fall risk, and delayed wound healing.
The failure to notify the physician and family member meant that critical medical assessment and intervention were delayed. During this period, the resident continued to lose weight, potentially worsening their overall health status and prognosis.
Range of Motion Services Also Affected
Inspectors identified additional notification failures involving Resident 19, who was classified as high-risk for developing contractures. The facility failed to report when this resident refused range of motion exercises provided by restorative nursing aides, despite facility policies requiring such notifications.
Contractures occur when muscles, tendons, and other tissues shorten and harden, leading to permanent joint stiffness and reduced mobility. For residents already at high risk, consistent range of motion exercises are essential preventive interventions.
When residents refuse these critical services, immediate notification allows medical teams to develop alternative approaches or address underlying concerns causing the refusal. Without proper communication, residents may develop irreversible joint limitations affecting their quality of life and functional independence.
Regulatory Requirements and Standards
Federal nursing home regulations specifically require facilities to immediately inform residents, their physicians, and responsible parties about any injuries, significant changes in condition, or room changes that affect the resident's care. These notification requirements are designed to ensure all members of the care team can respond appropriately to changing health needs.
The Centers for Medicare & Medicaid Services considers these communication failures serious violations because they can directly impact resident outcomes. When families and physicians are not informed of changing conditions, opportunities for early intervention may be lost.
Proper notification protocols should include documenting the change, contacting the physician within 24 hours, and notifying the responsible party or family member as soon as possible. This ensures coordinated care and allows for timely medical decisions.
Facility Response and Oversight
Colonial Care Center received citations for minimal harm with potential for actual harm, indicating inspectors determined these failures could have led to more serious consequences if left unaddressed. The facility is required to develop and implement corrective action plans addressing these notification deficiencies.
Federal inspection records show these violations occurred despite existing facility policies requiring change-of-condition reporting. The gap between written policies and actual practice highlights the importance of staff training and consistent implementation of communication protocols.
Long Beach residents and their families should be aware that nursing homes are legally required to maintain open communication about health status changes. When selecting or monitoring care at nursing facilities, families should ask about notification procedures and request immediate contact for any significant health changes.
The complete federal inspection report contains additional details about Colonial Care Center's compliance with various nursing home regulations and is available through the Centers for Medicare & Medicaid Services database.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.