Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa Coloma Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe environment and properly implement safety measures for three residents. A resident with cognitive impairment ingested chemical preservatives from an unsecured urine specimen tube left at the bedside, contrary to policy requiring specimens to be kept in a secluded location. Another resident with epilepsy had a physician order and care plan for padded side rails and seizure precautions, yet observations showed unpadded side rails, CNAs were unaware of the need for pads, and there was no documentation of refusal despite MAR entries indicating padding. A third resident with severe cognitive impairment had a bed remote with frayed, exposed wires accessible at the bedside; both a CNA and the maintenance director confirmed the condition, which conflicted with policies requiring the environment and equipment to be maintained free of accident hazards.
The facility failed to ensure accurate accountability of controlled medications, including tramadol, due to procedural lapses. An LPN disposed of tramadol without a second nurse to cosign, and medication cart-controlled drug sign-in/sign-out sheets had missing signatures. Additionally, the narcotic destruction process was not properly documented, with only the pharmacist's signature on the logs.
A facility was found to have an 8.82% medication error rate during a medication pass, exceeding the acceptable threshold. Errors included a nurse administering acarbose after breakfast instead of with the first bite, and another nurse failing to prime a Humalog KwikPen before injection. The Director of Nursing confirmed the lack of specific training on medication delivery devices.
The facility failed to label multi-dose medications with open and discard dates, risking the use of expired medications. Inspections revealed unlabeled inhalers and improperly stored ampules, contrary to manufacturer instructions and facility policies. The DON misunderstood labeling requirements, leading to non-compliance with medication storage protocols.
The facility failed to ensure food safety by allowing expired food items and improper storage conditions, including expired beverages in the refrigerator and a box soaked with cooking oil in the dry storage area. Additionally, there were physical environment issues such as a cracked light cover and missing light covers, posing contamination risks. The facility also lacked air gaps in sinks, increasing the risk of backflow contamination, and could not provide relevant policies or guidelines.
A LTC facility failed to maintain effective infection control, as staff did not use proper PPE for residents on droplet precautions, and residents were not offered hand hygiene before meals. Additionally, enteral feeding equipment was not labeled or changed as required, and a glucometer was improperly disinfected, increasing infection risks.
The facility failed to provide hot water in bathroom sinks for several residents and an entire hall due to a malfunctioning water heater pump. Residents, including those with rheumatoid arthritis, reported discomfort and difficulty washing with cold water. Staff were aware and reported the issue, but it remained unresolved for over 20 days. The Director of Maintenance confirmed the need for pump replacement, and the Administrator acknowledged the issue, but residents did not consistently receive alternative solutions.
The facility failed to respond to call lights in a timely manner for two residents, one with heart and kidney disease and another with irritable bowel syndrome, due to a muted call system at a nursing station. This resulted in significant delays in assistance, with one resident experiencing a fall. The facility's policy required call lights to be answered within five minutes, but the muted system and staff unawareness led to prolonged response times.
The facility failed to follow physician orders and medication administration protocols for several residents. A resident had conflicting orders for a knee brace, another had incorrect oxygen therapy settings, and a third was monitored for a discontinued medication. Additionally, loose pills were found at a resident's bedside, contrary to policy.
A resident with sensorineural hearing loss was not assisted with their hearing aids, leading to frustration and communication difficulties. Despite repeated requests for help, staff failed to address the malfunctioning hearing aids, and inaccurate documentation was noted. The facility's policy on assistive devices was not followed, impacting the resident's psychosocial well-being.
A resident with a feeding tube was not properly positioned with the head of bed elevated at 30-45 degrees during feedings, as required by physician orders and care plans. Observations showed the resident lying almost flat, increasing the risk of aspiration. Despite reminders and posted signs, staff failed to adhere to the prescribed positioning, compromising the resident's safety.
Two residents with COPD received oxygen at higher rates than prescribed, despite documentation indicating otherwise. Observations showed discrepancies in oxygen delivery, which were acknowledged by an LPN. The facility's policy on oxygen administration was not followed, leading to incorrect therapy.
A resident was administered quetiapine without adequate indication or non-pharmacological interventions. The facility failed to document the necessity of the medication or attempt non-drug interventions, leading to unnecessary medication use.
A resident with multiple health conditions did not receive restorative nursing services after being discharged from PT/OT due to insurance limitations. Despite being cognitively intact and expressing a desire for therapy, the necessary orders were not entered into the EHR, and the referral process was not completed. This failure resulted in the resident not maintaining her highest practicable level of well-being.
A resident in the facility was found without an accessible call light, as it was bundled and out of reach. The resident, who required assistance due to multiple health issues, was unable to call for help, increasing the risk of falls. The issue was confirmed by staff, who acknowledged the call light should have been reported for maintenance. The facility's policy mandates that call systems remain functional and accessible, which was not followed in this case.
The facility failed to meet the required 80 square feet per resident in 32 rooms, affecting residents' privacy and mobility. Interviews revealed residents' discomfort with crowded conditions and staff challenges in providing care efficiently due to limited space.
A resident with chronic pain and morbid obesity received lidocaine patches applied by a CNA, which is outside the CNA's scope of practice. Interviews revealed that CNAs were not permitted to apply such patches, a task reserved for licensed nurses. Despite this, a CNA admitted to applying the patches, and a nurse acknowledged leaving them with CNAs. The facility's policy stated only licensed personnel could administer medications, leading to a deficiency in professional standards.
The facility failed to maintain a secure environment for residents, as sliding glass doors in two residents' rooms could not be locked. A resident, admitted with depression and cognitively intact, felt unsafe due to the non-functional lock, which had been an issue for three years despite requests for repair. Observations confirmed the doors could not be locked, posing a security risk. The DON was unaware of the issue, which violated the facility's maintenance policy.
A CNA failed to follow infection control practices by handling soiled linen without gloves and neglecting hand hygiene before handling clean linen. The DON acknowledged the lapse, which violated the facility's policies on laundry handling and hand hygiene.
Failure to Maintain Safe Environment, Implement Seizure Precautions, and Maintain Equipment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and equipment maintenance for multiple residents. For one resident with moderate cognitive impairment, anxiety, hearing deficit, and macular degeneration, staff left a urine specimen collection pack containing preservative additives (Boric Acid, Sodium Borate, and Sodium Formate) unsecured at the bedside. According to the SBAR dated 3/18/26, during morning rounds a CNA observed this resident opening the biohazard specimen kit, removing the tube’s lid, and ingesting an unknown amount of the white material inside, which was then seen on the resident’s lips and tongue, along with increased confusion. An IDT note later documented that the nurse had inadvertently left the urine specimen collection pack near the bedside cabinet instead of securing it in the designated storage area, contrary to the facility’s policy that cultures and specimens be kept in a secluded location. The deficiency also includes the facility’s failure to implement a physician’s order for seizure precautions for a resident with epilepsy and intact cognition. A physician order directed nursing staff to monitor placement of padded side rails every shift, and the resident’s care plan identified risk for injury related to seizure disorder with an intervention to monitor side rail placement every shift. Observations on two separate days showed the resident in bed with side rails that were not padded. During interviews, CNAs familiar with the resident’s care needs stated they had not seen foam side rail pads used for this resident and were not aware they were needed, despite foam pads being used for other residents. The resident reported a history of epilepsy and seizures and stated awareness that side rails should be padded to prevent injuries in case of a seizure, but that nobody had placed the pads. The DON confirmed that foam side rail pads are used for residents on seizure precautions, that the side rails must be padded for safety, and that there was no documentation of the resident refusing side rail padding, despite MAR entries indicating side rails were padded. A further deficiency was identified in relation to equipment maintenance for another resident with severe cognitive impairment, encephalopathy, dementia, epilepsy, and diabetes. During observation, this resident’s bed remote control was seen next to the resident in bed, with frayed and exposed wires at the junction of the remote and cord and where the cord was wrapped around the bed rail. The resident stated he was able to use the bed remote and was observed picking it up. A CNA confirmed the presence of frayed and exposed wires and stated that this should not be and that it could shock the resident if he touched the frayed wire. The Director of Maintenance also confirmed the frayed and exposed wires on the bed remote control cord, acknowledged that the remote still worked but needed to be changed, and stated this was the first time he had been notified of the issue. These conditions were inconsistent with the facility’s policies requiring the environment to be as free from accident hazards as possible and requiring maintenance of equipment in a safe and operable manner at all times. Collectively, these events show that the facility did not follow its own policies on securing specimens, implementing seizure safety measures, and maintaining equipment, resulting in one resident ingesting chemical preservatives from a specimen tube, placing another resident at risk for injuries during seizure activity due to lack of padded side rails, and creating an electrical safety hazard for a resident with access to a bed remote with frayed, exposed wiring.
Failure to Ensure Accurate Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications, specifically tramadol, due to several procedural lapses. Licensed Nurse 7 (LN 7) disposed of tramadol without a second nurse to cosign the destruction, as required by the facility's policy. LN 7 later requested another nurse, LN 2, to cosign the destruction without having witnessed it. Both nurses acknowledged the importance of following the facility's policy to prevent misuse of narcotic medications. The Director of Nursing (DON) admitted that the staff did not adhere to the policy because of their long-standing trust in each other. Additionally, the facility's medication cart-controlled drug sign-in/sign-out sheets were found to have missing signatures from outgoing and incoming nursing shifts, indicating a failure to properly reconcile the inventory of controlled medications. The DON confirmed that it was policy for nursing staff to count narcotics between shift changes and sign the sheets immediately. Furthermore, the narcotic destruction process conducted by the Consultant Pharmacist and the DON was not properly documented, as the destruction logs only contained the pharmacist's signature. The DON acknowledged that she should have signed the logs at the time of destruction.
Medication Administration Errors Observed
Penalty
Summary
The facility was found to have an 8.82% medication error rate during a medication pass observation, exceeding the acceptable threshold of 5%. This was observed when three medication errors occurred out of 34 opportunities. Specifically, Licensed Nurse 6 (LN 6) administered acarbose to Resident 138 after breakfast, contrary to the physician's order to administer it with the first bite of the meal. Additionally, LN 6 mistakenly administered ferrous sulfate instead of the prescribed ferrous gluconate. LN 6 acknowledged these errors during an interview, confirming the deviation from the prescribed orders. Another error was observed with Licensed Nurse 1 (LN 1) during the administration of Humalog KwikPen to Resident 101. LN 1 failed to prime the pen before injection, which is necessary to ensure the correct dosage is delivered. LN 1 was unaware of the specific handling instructions for the Humalog KwikPen, which were outlined in the manufacturer's labeling. The Director of Nursing (DON) confirmed that nursing staff were expected to follow the medication administration record and physician's orders, but acknowledged that staff had not received specific training on the use of delivery devices like the Humalog KwikPen.
Failure to Label Multi-Dose Medications with Open and Discard Dates
Penalty
Summary
The facility failed to ensure that multi-dose medications were properly labeled with open and discard dates, which could lead to the use of medications beyond their discard date. During an inspection of Medication Cart 5, a Stiolto Respimat inhaler and a fluticasone/salmeterol inhaler were found opened and unlabeled with open dates. Licensed Nurse 6 confirmed that the manufacturer's labeling indicated specific discard dates after the inhalers were first used, which were not adhered to. Similarly, an inspection of Medication Cart 1 revealed three budesonide ampules not stored in their foil pouch, and without an open date, contrary to the manufacturer's instructions. The Director of Nursing (DON) indicated a misunderstanding regarding the labeling and expiration dates, stating that she was instructed to follow the expiration date on the pharmacy label. The facility's policies and procedures (P&P) for administering and storing medications require that the expiration or beyond-use date be checked prior to administration and that the date opened be recorded on multi-dose containers. The nursing staff is responsible for maintaining medication storage in a safe and orderly manner, which was not followed in these instances.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food safety by allowing expired food items and improper storage conditions in the kitchen. During an observation, a container of prepared apple juice and a container of iced tea concentrate were found expired in the walk-in refrigerator. The Dietary Aide confirmed these items should have been discarded the previous day. Additionally, a box soaked with cooking oil was found in the dry food storage area, which was not properly labeled or maintained. The Director of Dietary Services confirmed the expectation for staff to maintain a sanitary environment by labeling and dating items and ensuring cleanliness. Further deficiencies were noted in the facility's physical environment, including a cracked light cover between the steam table and food prep area, and missing light covers in the dry storage area. These issues pose a risk of physical debris contaminating food. Moreover, the facility lacked air gaps in the food production sink, the three-compartment sink, and the large sink next to the dishwasher, increasing the risk of backflow contamination. The facility could not provide any policy or guideline regarding air gaps, which is a requirement according to the 2022 Federal FDA Food Code.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during a survey. Staff did not adhere to proper infection control protocols for residents on droplet precautions. Specifically, staff entered the rooms of two residents with confirmed influenza without donning the required personal protective equipment (PPE), such as gowns and gloves. Despite signs indicating droplet and contact precautions, staff members either misunderstood the requirements or neglected to follow them, increasing the risk of infection transmission. Additionally, the facility did not consistently offer hand hygiene opportunities to residents before meals. Several residents reported that they were not provided with the means to wash or sanitize their hands before eating, despite the presence of hand sanitizing supplies on food carts. Observations confirmed that staff sanitized their own hands but failed to offer the same to residents, which is a critical step in preventing the spread of infections. The facility also demonstrated lapses in the management of enteral feeding equipment and glucometer disinfection. Enteral feeding bags and syringes were not labeled or changed according to the facility's policy, and a glucometer was cleaned with a wipe not approved by the manufacturer. These oversights in equipment management further contributed to the potential for infection spread among the vulnerable resident population.
Facility Fails to Provide Hot Water in Bathroom Sinks
Penalty
Summary
The facility failed to provide hot water in the bathroom sinks for 5 out of 33 sampled residents, including Residents 3, 108, 137, 20, and 110, as well as the entire Hall 30, which housed 24 residents. This issue persisted for over 20 days due to a malfunctioning water heater pump that was turned off, resulting in residents not having comfortable water to wash their hands and faces. The deficiency was observed through interviews and direct observations, where residents and staff reported the prolonged time it took for water to become lukewarm, if at all. Resident 3, who has rheumatoid arthritis, expressed discomfort with the cold water, stating it was painful and difficult to wait for it to warm up. Other residents, such as Resident 108 and Resident 137, also reported similar issues, with Resident 108 noting it took 20-30 minutes for the water to become lukewarm. Staff, including CNAs, were aware of the problem and had reported it to maintenance and administration, but the issue remained unresolved for an extended period. The Director of Maintenance confirmed the water heater pump was leaking and needed replacement, which was identified 20 days prior. Despite the facility's policy requiring monthly monitoring of water temperatures, the logs showed that temperatures were not checked in the affected areas due to the broken equipment. The Administrator acknowledged the issue and stated that staff were instructed to provide warm water from the utility room, but residents reported not receiving this assistance consistently.
Delayed Call Light Response and Muted Call System
Penalty
Summary
The facility failed to ensure timely response to call lights for two residents, Resident 108 and Resident 3, which compromised their ability to receive necessary assistance. Resident 108, who was admitted with heart and kidney disease and was at high risk for falls, reported that call light responses were particularly delayed at night, leaving her without help when in pain or needing assistance to use the bathroom. Similarly, Resident 3, who had irritable bowel syndrome and muscle weakness, experienced significant delays in call light responses, sometimes waiting up to an hour for assistance, which led to a fall when she attempted to move from the commode to her bed without help. The facility's call system at nursing station 1 was found to be muted, preventing staff from being alerted to residents' calls for assistance. During an observation, call lights were on for several rooms, but there were no audible alerts from the phone system at the nursing station, and staff were unaware of the calls while they continued with their tasks. The Administrator confirmed the issue with the muted call system and acknowledged that the lack of audible alerts could delay response times to residents' needs. The facility's policy required that call lights be answered as soon as possible, but not later than five minutes. However, the muted call system and the staff's unawareness of the call lights resulted in significant delays in responding to residents' needs, as evidenced by the experiences of Resident 108 and Resident 3. This failure to respond promptly to call lights had the potential to jeopardize the health and safety of residents by not meeting their care needs in a timely manner.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that physician orders were appropriate and followed as ordered for several residents, leading to potential adverse outcomes. Resident 94 had conflicting orders for a knee brace, with one order indicating a brace for the left knee and another for the right knee. Interviews with the resident and staff revealed confusion about which order was correct, and it was acknowledged that the order for the right knee brace was the correct one. Additionally, Resident 94 had an order for oxygen therapy at 2 liters per minute, but observations showed the oxygen concentrator set at higher levels without appropriate orders to adjust the flow rate. Resident 37's case involved the continuation of monitoring for a medication that had been discontinued. The medication Mirtazapine was no longer being administered, yet staff continued to document monitoring for its side effects and behavior as if it were still in use. This oversight was acknowledged by the Director of Nursing, who stated that all related orders should have been discontinued when the medication was stopped. Resident 109 was found to have loose pills in a medication cup at the bedside, which was against the facility's policy. The resident required assistance with medication administration due to coordination issues, and the medication should have been administered directly by the nurse. The Director of Nursing confirmed that leaving medication at the bedside was not compliant with the facility's procedures, highlighting a lapse in ensuring proper medication administration practices.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 87, received necessary assistance with their hearing aids, which were crucial for their communication and social interaction. Resident 87, who was admitted with sensorineural hearing loss and other medical conditions, expressed frustration and anger due to the inability to hear and communicate effectively. Despite the resident's repeated requests for assistance in getting an appointment to repair the hearing aids, staff did not provide the necessary help. Observations confirmed that the hearing aids were not in use, and staff interviews revealed a lack of action in addressing the resident's complaints. The facility's staff, including a CNA and a licensed nurse, acknowledged the importance of the hearing aids for Resident 87's communication and psychosocial well-being. However, the licensed nurse failed to report the malfunctioning hearing aids to Social Services, despite being aware of the issue for over a week. The nurse also inaccurately documented that the hearing aids were functioning and in use. The Director of Nursing confirmed that staff are expected to follow physician orders regarding assistive devices and report any malfunctions immediately. The facility's policy on assistive devices emphasizes the maintenance and supervision of such devices, but this was not adhered to in the case of Resident 87.
Failure to Maintain Proper Head of Bed Elevation for Tube Feeding
Penalty
Summary
The facility failed to ensure the safety of a resident with a feeding tube by not following the physician's order to keep the head of bed (HOB) elevated at 30-45 degrees during tube feeding. This deficiency was observed on multiple occasions, where the resident was found lying almost flat while receiving tube feeding, contrary to the physician's order and the care plan. The resident's medical history included conditions such as pneumonitis due to inhalation of food, lung disease, and dysphagia, which increased the risk of aspiration. Observations and interviews with licensed nurses and certified nursing assistants confirmed that the resident's HOB was not elevated as required, despite a sign posted above the bed indicating the need for elevation. The speech therapist also noted the improper positioning during therapy sessions and emphasized the importance of maintaining the correct HOB elevation to prevent aspiration. The facility's policy on enteral feedings required staff to be trained and competent in preventing aspiration by ensuring the HOB was elevated during and after feedings. The Director of Nursing acknowledged the risk of aspiration for residents receiving tube feeding and stated the expectation for staff to follow the physician's orders and speech therapist's instructions. Despite these expectations, the resident's improper HOB positioning was repeatedly observed, indicating a failure to adhere to the prescribed care plan and facility policy, potentially compromising the resident's safety.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that two residents, both with chronic obstructive pulmonary disease (COPD), received oxygen therapy as prescribed by their physicians. Resident 78, admitted in the fall of 2024, was ordered to receive oxygen at 2 liters per minute via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set to deliver 3.5 liters per minute. Similarly, Resident 93, who was admitted in 2022, was also prescribed 2 liters per minute of oxygen but was observed receiving 3 liters per minute. Both residents' medication administration records indicated that nurses had documented the administration of oxygen at the prescribed rate, despite the discrepancies observed. During interviews, Licensed Nurse 1 acknowledged the discrepancies in oxygen delivery rates for both residents, confirming that the rates were higher than the physician's orders. The Director of Nursing was informed of these issues and stated that the expectation was for nurses to follow physician orders. The facility's policy on oxygen administration, which emphasizes verifying physician orders and reviewing care plans, was not adhered to, leading to the incorrect administration of oxygen therapy.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 47, was free from unnecessary psychotropic medications. Resident 47 was administered quetiapine, an antipsychotic medication, without the implementation of non-pharmacological interventions and without adequate indication for its use. The resident's medical record did not contain documentation to support the necessity of the medication, and non-drug interventions were not attempted prior to or alongside the medication. Resident 47 was admitted with diagnoses including dementia with unspecified psychosis and recurrent urinary tract infections. Upon admission, the resident was described as agitated and difficult to manage, leading to the reintroduction of quetiapine, which had been used during a prior hospital stay. However, the facility did not have an order to continue the medication upon discharge from the hospital, and the documentation did not support the use of quetiapine for the resident's behavior, which was not persistent or adequately evaluated for underlying causes. The Director of Nursing confirmed that the facility's policy required documentation to support the use of antipsychotic medications and the implementation of non-pharmacological interventions. The facility's policy also indicated that antipsychotic medications should only be used after identifying and addressing medical, physical, and psychological causes of behavioral symptoms. Despite this, the facility did not adhere to these guidelines, resulting in the unnecessary administration of quetiapine to Resident 47.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) for a resident, identified as Resident 15, who was admitted with multiple diagnoses including primary osteoarthritis, heart failure, COPD, type 2 diabetes, and unspecified difficulty in walking. Despite being cognitively intact, Resident 15 reported not receiving physical or occupational therapy for several months and expressed a desire to regain some independence. The resident had initially received some therapy upon admission but had not been offered any restorative services after being discharged from PT/OT due to insurance limitations. The Director of Rehabilitation (DOR) claimed that Resident 15 refused treatment, but there was no documentation in the clinical record to support this claim. The resident was supposed to be referred to the RNS program after PT/OT discharge, but the process was not completed. The Director of Staff Development (DSD) and RNA 2 confirmed that the necessary orders were not entered into the electronic health record (EHR), and the referral form was not received by the DSD, resulting in a failure to initiate restorative services. The facility's policy indicated that residents should receive restorative nursing care to promote safety and independence, especially after being discharged from rehabilitative care. However, due to a breakdown in communication and process adherence, Resident 15 did not receive the necessary care to maintain her level of functioning, which could have impacted her physical, functional, and emotional well-being.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to provide an accessible call light for one of the sampled residents, Resident 117. During an observation, it was noted that the call light was bundled up and attached to the call light plate, making it out of reach for Resident 117. This deficiency was confirmed during a joint observation and interview with two licensed nurses, who acknowledged that the call light was not accessible and that it should have been reported to maintenance for repair. The call light was eventually provided to Resident 117, but the delay in addressing the issue left the resident without a means to call for assistance. Resident 117 was admitted to the facility with multiple diagnoses, including protein calorie malnutrition, weakness, and abnormalities with gait and mobility. The resident was moderately cognitively impaired and required moderate assistance or supervision for various activities, including toileting and bathing. The care plan for Resident 117 emphasized the importance of having a call light within reach to prevent falls and ensure assistance could be requested when needed. The facility's policy also required that the resident call system remain functional at all times and be routinely maintained, which was not adhered to in this instance.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 32 resident rooms met the required 80 square feet per resident, as observed during a survey. The rooms in question housed three residents each, with measurements ranging from 72.4 to 76.7 square feet per resident, falling short of the regulatory requirement. The Administrator confirmed that there were no current room waivers in place for these rooms, and room measurements provided by the facility corroborated the deficiency. Interviews with residents revealed concerns about the lack of space affecting their quality of life. Residents reported issues such as compromised privacy, difficulty moving around due to crowded conditions, and challenges in accommodating personal belongings and equipment. Some residents expressed discomfort with the lack of privacy during personal conversations and the inconvenience of sharing a single television among three people. Staff interviews indicated that the room size occasionally hindered their ability to provide care efficiently. Licensed nurses and nursing assistants mentioned the need to reposition beds and move personal items to facilitate resident transfers, which sometimes slowed down their work. Despite these challenges, some staff members reported not hearing complaints from residents about room size, while others acknowledged the spatial limitations as a minor issue in their daily tasks.
Improper Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when a Certified Nursing Assistant (CNA) administered medication to a resident, which was outside their scope of practice. The incident involved a resident who was admitted to the facility with chronic pain and morbid obesity. The resident's medication orders included the application of a lidocaine patch for pain management. During an observation, a lidocaine patch was found on the resident's bedside table, and the resident confirmed that CNAs applied the patches. Interviews with staff revealed that CNAs were not permitted to apply lidocaine patches, as this task was reserved for licensed nurses. Despite this, one CNA admitted to applying the patches, and a licensed nurse acknowledged leaving the patches with CNAs to apply later. The facility's policy clearly stated that only licensed personnel were authorized to administer medications, and the CNA job description specified that CNAs should provide non-pharmacological interventions for pain. This discrepancy between policy and practice led to a deficiency in the facility's adherence to professional standards.
Facility Fails to Maintain Secure Living Environment
Penalty
Summary
The facility failed to ensure a safe and functional living environment for residents, as evidenced by the inability to lock sliding glass doors in the rooms of two residents. Resident 1, who was admitted in 2021 with a diagnosis of depression and was cognitively intact, reported feeling unsafe due to the non-functional lock on her sliding glass door. Despite her repeated requests for repairs over three years, the issue remained unresolved. During an interview and observation, both Resident 1 and a Certified Nursing Assistant (CNA) confirmed the door could not be locked, posing a potential security risk as it allowed unauthorized access from outside. Similarly, the sliding glass door in Resident 3's room was also found to be non-lockable. A CNA confirmed the door was broken and acknowledged the safety issue it presented. The Director of Nursing (DON) was unaware of the problem until informed during the survey and recognized the safety concern, as it allowed potential entry from outside and access by other residents. The facility's policy mandates that the Maintenance Department is responsible for ensuring all equipment is safe and operable, which was not adhered to in this instance.
Infection Control Breach by CNA
Penalty
Summary
The facility failed to adhere to infection control practices when a Certified Nursing Assistant (CNA 1) did not use gloves while handling soiled linen and neglected proper hand hygiene after touching soiled linen. During an observation, CNA 1 was seen holding a soiled gown and linens with bare hands, transporting them from a resident's room to a soiled linen bin in the hallway. Subsequently, CNA 1 accessed the clean linen closet, retrieved two clean gowns, and proceeded to a resident's room without performing hand hygiene after handling the soiled items. The Director of Nursing (DON) confirmed that the staff should have used a bag for transporting soiled linen, worn gloves when handling soiled items, and performed hand hygiene afterward. The facility's policy on laundry and linen, dated January 2014, requires washing hands after handling soiled linen and before handling clean linen. Additionally, the handwashing/hand hygiene policy, dated August 2019, mandates that all personnel follow hand hygiene procedures to prevent the spread of infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rancho Cordova
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River City Post Acute | 1.8 mi | ★★★★★ | 45 | 0 |
| River Pointe Post-acute | 1.8 mi | ★★★★★ | 35 | 0 |
| Mountain Manor Senior Residence | 1.9 mi | ★★★★★ | 2 | 0 |
| American River Center | 3.4 mi | ★★★★★ | 12 | 0 |
| Whitney Oaks Care Center | 3.4 mi | ★★★★★ | 6 | 0 |
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