Colonial Care Center
COLONIAL CARE CENTER in LONG BEACH, CA — inspection on January 29, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of the GACH's Orthopedic Consultation report, dated 1/5/2026, and timed at 9:37 a.m., the Orthopedic Consultation indicated Resident 1's injury was likely due to malunion (a broken bone that healed in an abnormal, misaligned position) and surgery was not recommended due to Resident 1's dementia and non-ambulatory status.
The report indicated Resident 1 was stable for discharge from an orthopedic standpoint.
During an interview on 1/28/2026 at 4:40 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 required a two-person assist for care. On 1/2/2026 she and CNA 2 provided care to Resident 1 during the 3 p.m. to 11 p.m., shift. CNA 1 stated sometime during the evening (time unknown), she and CNA 2 noticed Resident 1's right knee was bending weirdly. CNA 1 stated they (CNA 1 and CNA 2) informed LVN 1, LVN 1 repositioned Resident 1 and accidentally bumped the resident's right knee on bed frame.
During an interview on 1/29/2026 at 10:13 a.m., LVN 1 stated on 1/2/2026, at around 9:30 p.m., while making rounds, she found Resident 1 at the edge of the right side of her bed, with her right foot hitting the bed's footboard. LVN 1 stated she knew Resident 1 was a two-person assist but everyone was busy caring for other residents', to prevent Resident 1 from falling she decided to reposition Resident 1 without assistance. LVN 1 stated she used a draw sheet (a small, folded bed sheet or specialized fabric placed across the middle of a mattress, covering the area between a patient's upper back and thighs.
Primarily used to reposition, lift, or transfer patients) to pull Resident 1 up while Resident 1's right leg was crossed over the left leg; both legs were straight. LVN 1 stated Resident 1 was centered in the middle of the bed and as she proceeded to turn Resident 1 toward the left side of the bed, Resident 1 moved her legs, and her right knee hit the bed frame on the bottom of her bed that was exposed because the mattress did not cover the bed frame completely. LVN 1 stated she noticed Resident 1 was grimacing, moaning, and she observed redness and swelling on the resident's her right knee.
During an interview on 1/29/2026 at 11:54 a.m., the Director of Nursing (DON) stated LVN 1 should have called for help if Resident 1 required a two-person assist.
During a review of the facility's undated P/P, titled, Positioning & Moving Residents the P/P indicated before moving or lifting a resident, staff members were to assess the resident's physical abilities, mobility limitation in joints and muscles, strength, awareness of surroundings, and ability to follow directions.
Staff members will use maximum precautions when moving or lifting residents, obtain assistance from other professional as needed.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.