Avir at Coronado

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #5) reviewed for care plans. The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, Resident #3, Resident #5 described the resident's goals for admission and desired outcomes, preference and potential for future discharge, and an assessment of their desire to return to the community. These failures could place the residents at risk of not receiving adequate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident had the right to receive mail, and to receive letters, packages and other materials delivered to the facility for the residents unopened for 1 of 7 (Resident #7) reviewed for resident rights. The facility failed to ensure that Resident #7 received his mail and packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests and rodents. The facility failed to ensure an effective pest control program was in place to keep American roaches out of the facility. This failure could affect all 68 residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026) of 54 days (03/01/2026 - 04/24/2026) reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026. This failure leaves residents without the nursing administrative oversight that only the DON can provide.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #37, Resident #54 and Resident #67) of 5 residents reviewed for resident rights. The facility failed to:Ensure Resident #37's ileostomy collection bag was obscured from view. Ensure Resident #54's urinary catheter collection bag was obscured from view. Ensure Resident #67 colostomy and indwelling urinary collection bags were emptied and obscured from view. These failures could place residents at risk for feeling uncomfortable and disrespected, leading to isolation and deterioration in general health conditions.

Inspectors wroteBased on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 12 of 15 confidential residents reviewed for meeting grievances. The facility failed to provide a verbal or written response to the Resident Council addressing the grievances reported from their meetings on May 2025, August 2025, September 2025, January 2026, February 2026, and March 2026, which included issues with nursing services, dietary services, and housekeeping services. This failure could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 7 of 19 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) resident rooms observed for environmental conditions. The facility failed to ensure rooms 231 B, 233 A, 234 A, 234 B had mattresses that the nonpermeable outer cover was intact and not peeling. The facility failed to ensure rooms 201, 209, 210, and 218's sinks had hot water. These failures could place residents at risk for diminished quality of life, discomfort, and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 4 of 18 (Resident #2, 3, 4, 33) residents reviewed for care plans. The facility failed to develop a comprehensive care plan for Resident #2 that included her Diagnoses of Anxiety and Major Depressive Disorder. The facility failed to develop a comprehensive care plan for Resident #3 that included smoking cigarettes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with a nourishing, well-balanced diet to meet the daily nutritional and special dietary needs for 21 of 73 residents reviewed for food and nutrition services. The facility did not provide 21 residents on a regular diet who were supposed to be served refried beans for lunch or offer a comparable substitute when they ran out of refried beans. This failure could place residents who ate food from the kitchen at risk of not having their nutritional needs met and possible weight

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:A. The floors throughout the kitchen were clean and free from dirt and food crumbs. B. The stand that the mixer was on was clean and free from dirt and food crumbs. C. The plastic container that contained the food thickener was free from spilled food and not soiled. D. The convection oven and stove were clean on the inside and outside. E. The shelf above the stove was clean and not soiled with food crumbs and dust. F. The refrigerator was clean and free of food crumbs and dust. G. The stand that held the residents' plates was clean and free of food crumbs. [...]

Inspectors wroteBased on interview, and record review, the facility failed to accurately assess each resident's status for 1 of 19 (Resident #4) residents reviewed for assessment accuracy. The facility failed to ensure the assessment information in Resident #4' s admission MDS, dated [DATE], was accurate. This failure could place residents at risk of not receiving the proper care and services due to inaccurate assessment records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #33) of 2 residents reviewed for catheter care. The facility failed to ensure Resident #33's indwelling urinary catheter tubing was secured to her leg, and her catheter bag was emptied every shift. These failures could place residents at risk of catheter tubing leakage, resulting in cross-contamination and development of infections.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 19 (Resident #54) residents reviewed for nursing assessments. The facility failed to ensure readmission Assessment was included in the medical record for Resident #54 after hospitalization on 4/18/2026 per facility policy. This failure could put residents at risk of records not being completed and staff not having all information needed to provide quality care to its residents.

Inspectors wroteBased on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for qualified staffing. The facility failed to ensure they had a full-time licensed Social Worker. This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store drugs and biologicals in locked compartments during medication storage inspection for 1 (medication Cart #1) of 1 medication cart reviewed for storage. The facility failed to store drugs and biologicals in locked and secured while unattended. This failure could place residents at risk of drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6) reviewed for comprehensive person-centered care plans. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to a nurse aide with the responsibility for the resident for 6 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. This failure could place residents at risk for not receiving the care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. 1. The facility failed to ensure ground meat was thawed properly. 2. The facility failed to ensure the cook performed hand hygiene appropriately when preparing food. 3. The facility failed to ensure foods were sealed and/or labeled properly. 4. The facility failed to ensure the foods were not stored past expiration date. Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 23 residents (Resident #29 and Resident #44) reviewed for antipsychotic consents. 1. The facility failed to ensure Resident #29 or their representative signed consent for antipsychotic medication Seroquel (quetiapine) (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering medication and after dosage increased and prior to administering new dosage ordered by physician. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that: 1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. 2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 5 (Resident #5, Resident #17, Resident #22, Resident #43, and Resident #49) of 23 residents reviewed for food and nutrition services. The facility failed to ensure that Resident #17's personal refrigerator did not have expired goods stored and failed to log refrigerator's temperatures. The facility failed to ensure that Resident #43's personal refrigerator had a thermometer inside to check temperature and failed to log refrigerator ' s temperatures. The facility failed to ensure that Resident #22's personal refrigerator had temperature log during the month of February 2025 (last checked on 1/14/2025). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for (Resident #169) 1 of 23 resident's rooms observed for environmental conditions. The facility failed to ensure that Resident #169 ' s toilet was free from cracks at the base and was sturdily attached to the floor. The facility's failure placed the residents at risk for diminished quality of life, discomfort, and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #17) of 23 residents reviewed for medication storage. The facility failed to ensure medications were not left in Resident #17 ' s personal refrigerator. This failure could result in unauthorized persons having access to medication that was not intended for them or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #18) observed for infection control. 1. The facility failed to ensure CNA B used the required PPE for Resident #18, (gown) who was on enhanced barrier precautions due to her Foley Catheter while performing Foley Catheter Care on 02/19/25. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the residents a safe, clean, comfortable, and homelike environment for 2 of 4 residents (Resident #3 and Resident #8) reviewed for the right of a homelike physical environment. The facility failed to ensure Resident #3 and Resident #8's bathrooms were free live cockroaches, and the air conditioner window unit filters were free of being clogged with lint. The failures placed residents at risk of an unsanitary and uncomfortable environment and a decrease in quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law procedures for 1 of 5 residents (Resident #3) reviewed for reporting allegations of abuse, neglect, and exploitation. [...]

Inspectors wroteBased on interview, and record review the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 5 residents (Resident #3) reviewed for abuse. 1. The Administrator failed to investigate an alleged allegation of abuse when a family member of Resident #3 alleged Resident #3 had been abused by CNA B. 2. The facility failed to prevent further potential abuse or mistreatment by allowing CNA B to remain on duty after the facility became of aware of the alleged allegation of abuse. These failures could place residents at risk for abuse and neglect by not investigating and implementing preventive measures.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an effect pest control program to keep the facility free of roaches for two (2) common areas, and for 2 of 4 residents (Resident #3 and Resident #8) reviewed for pest control program. The facility failed to ensure the facility was free of roaches The facility failed to ensure Resident #3 and Resident #8's bathrooms were free live cockroaches This failure could affect residents by placing them at risk for potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 26 of 26 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) reviewed for infection control. 1. The facility failed to isolate COVID-19 positive Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15, after they tested positive for COVID-19 and continued to cohort with negative tested Residents #4, #6, #16, and #17 on the same unit. Resident #4 (negative) was cohorted with Resident #12 (positive) in the same room. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 (Resident #1) residents reviewed for elopement. The facility failed to provide supervision for Resident #1, who was care planed for wandering in unsafe places, to prevent him from eloping from the facility on 04/18/2024. The facility was unaware Resident #1 had exited the facility, the last time he was seen by an employee was 2:00 PM, and as a result, the resident was missing for approximately 6 and half hours and was located by assistance from law enforcement. An Immediate Jeopardy (IJ) was identified on 04/26/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 16 resident reviewed for abuse or neglect. The facility failed to report to the State Survey Agency allegations of Abuse and Neglect when learning of an elopement of Resident #1. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (Resident #2) of 3 residents reviewed for discharge requirements. 1. The facility failed to ensure Resident #2 was provided a discharge in writing 2. The facility failed to document a discharge summary. This failure placed residents at risk of not receiving necessary care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's comprehensive care plan contained interventions that addressed his need for supervision for wandering. This failure could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and record review the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 1 of 1 facility reviewed for sufficient staffing The facility failed to ensure the facility had sufficient staffing based off of facility assessment. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the nessary care and services to attain the highest practicable, physicial, mental, and psychosocial well-being consisted for 2 (Resident #10 and Resident #12) of 12 residents reviewed for quality of life The facility failed to ensure Resident #10 received showers per resident's request. The facility failed to ensure Resident #12 transferred from bed to chair per resident's request. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on interview and record reviews, the facility failed to accurately assess the residents' status for 4 (Resident #4, Resident #30, Resident #54, and Resident #324) of 6 residents reviewed for assessment accuracy. The facility did not accurately indicate on Resident #4, Resident #30, or Resident #54's MDS (Minimum Data Set) the results of a Brief Interview for Mental Status evaluation. The facility did not accurately indicate on Resident #324's MDS a urinary tract infection. These failures could place residents at risk for receiving inadequate or inappropriate care and services .

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #5, Resident #30, Resident #54, and Resident #65) of 7 residents reviewed for comprehensive person-centered care plans. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #7, Resident #10, and Resident #13) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. These failures could place residents at risk for injury.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance as well as failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal observed. The facility failed to provide a lunch meal that was flavorful and palatable. These failures can place residents at risk for weight loss. Findings Include: During an observation on 12/20/2023 at 11:41 AM, test meal arrived at 11:55 am. The meal consisted of Salisbury steak, cauliflower and broccoli vegetable mix, potato wedges, and a roll. The Salisbury steak and the cauliflower and broccoli vegetable mix was not flavorful and palatable. During an interview on 12/20/2023 at 3:30pm, DON stated that the meal was not flavorful and palatable. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen observed. The facility failed to ensure that opened food was labeled and dated with date open. These failures place residents at risk for food borne illness

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain infection control protocols to prevent infections for 1 of 2 resident (Resident #27) observed for catheter care needs. The facility failed to ensure CNA A used a peri-care cleaning wipe and cleaned catheter tubing toward the resident and not away toward catheter bag to clean catheter tubing. These failures place residents at risk for unnecessary infections while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bonds reviewed. The facility failed to ensure that the facility's $60,000.00 surety bond was enough to cover the $71,340.82 total residents' trust fund account balance. This deficient practice could affect all residents who deposited personal funds with the facility, and place residents at-risk of their personal funds not being assured.

Inspectors wroteBased on interviews and record reviews, the facility failed to make sure that the comprehensive care plan is prepared by a team that included the attending physician and a nurse aide with responsibility for the resident for 16 of 16 residents (Resident #26, #6, #10, #34, # 28, #4, #54, #13, #32, #57, #30, #65, #7, #14, #29, #18) reviewed for care plans. The facility failed to ensure the attending physicians and nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. These failures could place the residents at risk for not receiving the care and services to meet their needs

Inspectors wroteBased on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis. The facility failed to ensure facility had a full-time social worker. This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 6 of 6 days reviewed for RN Coverage. The facility failed to provide evidence a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 6 days (08/05/23, 08/06/23,08/19/23, 09/02/23, 09/03/23 and 09/30/23) of the FY Quarter 4 2023 (July1- September 30) out of 4 Quarters. This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and maintain an account of all controlled drugs for 1 of 24 controlled medications reviewed for security. The facility failed to ensure hydrocodone-acetaminophen 10-325mg, a prescribed narcotic medication, was secured. This failure could place residents at risk of not receiving prescribed narcotic medications and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured in accordance with currently accepted professional principals for 1 of 24 controlled medications reviewed for security. The facility failed to ensure hydrocodone-acetaminophen 10-325mg, a prescribed narcotic medication, was secured. This failure could place residents at risk of not receiving prescribed narcotic medications and pain.