Corona Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of three residents reviewed (Resident 2):1. Ongoing monitoring and assessment were provided, when there was a change of condition of injuries sustained from resident's fall to the posterior (back) head and right arm on February 5, 2026;2. There was no physician order to address the skin tear on the right arm; and3. There was no care plan developed to address the fall incident with injuries on February 5, 2026. These failures had the potential for injuries sustained from a fall incident not to monitored for any complications related to the fall and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for one or three residents reviewed for accidents (Residents 24 and 57):1. Two person-assistance was provided during incontinent care (cleaning the resident while in bed after periods of urination or bowel elimination) in accordance with the plan of care, for Resident 24. This failure resulted to Resident 24 fell from the bed, complaint of pain and swelling at the right thigh, which indicated fracture (broken bone) to the right thigh, and subsequently was sent out to the acute care hospital for further management; 2. The smoking paraphernalia (cigarette and lighter) were stored in a secured container according to facility policy and procedure, for Resident 57. This failure has the potential to place Resident 57 at risk for smoking related accidents

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety when: 1. Outside food items were not stored past the store by date and properly labeled according to the facility's policy and procedure; and2. The [NAME] did not disinfect the food thermometer in between use. These failures had the potential to cause food borne illness and food poisoning within their resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of safe and effective pharmaceutical services to meet the needs of the residents when:1. For Resident 39, cholestyramine (medication used to lower cholesterol and treat itching or diarrhea caused by a buildup of bile acids [substances made by the liver that help digest fats]) was administered without appropriate separation from other oral medications, not in accordance with the manufacturer's instructions and the facility's consultant pharmacist's recommendation to separate administrations. This failure had the potential to result in reduced drug absorption, and inadequate medication treatment, compromising the effectiveness of other administered medications; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications in accordance with the facility's policies and procedures and/or manufacturer's instructions when:1. One discontinued and expired medication for Resident 107 was stored in Medication Refrigerator in Medication room [ROOM NUMBER] along with other active medications available for use;2. A total of four IV (intravenous, into a vein) Mini-Bag Plus containers, removed from manufacturer's overwrap, were stored without beyond use dates (BUD, date or time after which the product may not be used) in IV Emergency Kit (E-kit, a sealed container with various medications for use in emergencies) in Medication room [ROOM NUMBER]; and3. One expired inhaler for Resident 71 was stored in Medication Cart 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the cook (Cook 1) followed the recipe for pureed (blend food into soft consistency) vegetables. This failure has the potential to affect the consistency, taste, and nutritive value of the pureed menu items, and further affect the resident's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were upheld when:1. One licensed nurse was observed wearing long, acrylic nails while providing direct patient care;2. One licensed nurse was observed not to follow enhanced barrier precautions (EBP- a type of isolation precaution) while providing direct patient care to Resident 45; and3. For Resident 44, the nebulizer tubing and mask, as well as the Yankauer suction tip (type of suction tip), were not stored appropriately when not in use. These failures had the potential to spread infection among the vulnerable residents of the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure written information to formulate an Advance Directive (AD - written instruction for the provision of care and services when unable to make decisions for oneself) was provided to the resident or the resident representative, according to the facility's policy and procedure, for two of two residents (Resident 49 and Resident 88). This failure had the potential for the residents to receive unnecessary care/treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's policy and procedure on discharging a resident without a physician's approval was implemented, for one of three residents reviewed (Resident 102). This failure has the potential to place Resident 102 at risk for unsafe discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, for two of 20 residents reviewed (Residents 85 and 10):1. For Resident 85, had a follow-up appointment with neurology (study of the brain after hospital discharge) as ordered on the general acute hospital (GACH) discharge summary; and2. For Resident 10, the facility identified, monitored, and notified the physician in a timely manner, multiple skin discolorations on both hands and the left upper extremity. These failures had the potential for Residents 85 and 10 to have a delay in the care and treatment and placed the resident at high risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately conduct pain assessment, for one of one resident (Resident 24). This failure had the potential for Resident 24's pain to be unmanaged appropriately.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for one of one resident (Resident 7):- Post dialysis (a medical procedure that acts as an artificial kidney, used when a person's kidneys fail to remove waste and excess fluid from the blood) complications were appropriately monitored on July 21, 2025;- The physician was notified of Resident 7's low blood pressure after dialysis treatment; and- Resident 7 's low blood pressure was not monitored. These failures had the potential to result in the untimely reporting of adverse effects and symptoms post dialysis, which could also result in a decline in health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for one of five residents (Resident 69), when the nursing staff failed to clarify Resident 69's physician's order for lidocaine (medication for pain) 4% (percent, a unit of measurement for concentration) transdermal (topical) patches that directed application twice daily and failed to apply and remove the patch in accordance with both the physician's order and the manufacturer's instructions. This deficient practice had the potential to result in ineffective pain management, medication administration errors and compromised treatment outcomes as well as excessive lidocaine exposure and avoidable side effects such as skin irritation.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three resident (Resident 1) was free from misappropriation of property when the Social Service Designee (SSD) used Resident 1's bank card to purchase items for her personal use, without consent from Resident 1. This failure had the potential to affect Resident 1's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine and its components were properly cleaned and sanitized, for 87 of 90 residents who received ice from the the facility's ice machine. This failure had the potential to result in contamination of the ice being served to all residents and could lead to waterborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure devices used for the residents, were sanitary, clean, and disinfected properly, when: 1. The pill crusher was observed with brown sticky substance, for 15 of 27 residents which required medications to be crushed; and 2. The stand lift machine (a non-electric standing aid designed to assist seniors in safely rising from a seated position in chairs, couches, or recliners) was observed to be dirty, for one of one resident who uses the stand lift machine. These failures had the potential to result in the residents being exposed to unsanitary shared devices which could lead to spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and functional environment, for two of two residents who independently uses the smoking patio (Resident A and Resident B), when the fire door closed was dismantled. In addition, the ceiling above the fire door closer was observed to have water damage. These failures had the potential to cause injury to Residents A and B while entering or exiting through the fire door. In addition, the stained ceiling had the potential for it to collapse and could injure residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the system of identifying and monitoring fall risk residents for one of three sampled residents (Resident 1). This failure has the potential for the staff not to provide interventions to residents, resulting to recurrent falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure a consistent and accurate reconciliation of controlled medications (drugs or medications that possess the potential for being misused) for two sampled residents (Resident 1 and Resident 2). This failure resulted in loss of medications and the potential for Resident 1 and Resident 2 to experience preventable suffering and inadequate pain management. In addition, this failure increased the risk for drug diversion (unauthorized/illicit use).

Inspectors wroteBased on interview and record review, for three of eight residents reviewed for Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions), the facility failed to ensure: 1. For Resident 38 and 76, a copy of their formulated AD was available for review in the resident's medical records. This failure had the potential for Residents 38 and 76's treatment wishes to not be honored; and 2. For Resident 37, the POLST (Physician Orders for Life-Sustaining Treatment - a portable medical order form that records the resident's treatment wishes for emergency personnel reference) was completed by the resident's representative to indicate the resident's care treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled medications (narcotic medications - used to treat moderate to severe pain) were accounted for, for five of five residents reviewed (Residents 26, 32, 21, 6, and 39) when the narcotic medications were not documented on the Medication Administration Record (MAR) as administered to the residents. In addition, Resident 26 and 39's narcotic pain medication was not given as ordered by the physician. These failures had the potential to result in possible diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored and labeled according to the facility's policy and procedure when: 1. Multiple over the counter and treatment medications were not identifiable to be discarded or disposed of, were readily available for use in medication storage room at Station 1; 2. Three (3) Luer Lock (brand of syringe) IV (intravenous - through the vein) kits were found expired in the IV Cart; 3. Two (2) bags of 250 ml (milliliter - unit of measurement) normal saline IV were unlabeled and readily available for use in the IV cart; 4. For Residents 68 and 49, multiple medications of different forms and route were stored together in an area in the med cart of station three (3); 5. For Residents 85, 58, and 53, the discontinued meds were found stored in the med cart station three (3) readily available for use; and 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. Food preparation and cooking pans (19 sheet pans, 3 baking pans, 1 steamer pan, 4 small deep container pans, 5 small shallow containers) were stacked wet one on top of another; 2. Dust was observed in several kitchen storage shelves, equipment, and ventilation vents; 3. Observed rust on the metal storage shelves, back stove hood, and fire suppression water pipes; 4. Wooden shelves in storage room were found with chipped paint and dust; 5. Dietary Aide (DA) 3 was observed not removing gloves and washing hands, after handling trash; 6. Observed broken and missing floor tiles in the walk-in-refrigerator, walk-in-freezer, back stove area, and dishwashing machine area; and 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own policy and procedure to provide an environment free of pests, when black flies were observed flying and landing in the kitchen. This failure had the potential to lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure eligible residents were provided with a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-Coverage (ABN- a notice a provider gives after receiving services based on Medicare, federal funded program that covers skilled nursing facility in writing), for two of three residents reviewed for beneficiary notice (Residents 75 and 52). This deficient practice had the potential for the residents not to be informed of services should they decide to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS - a resident assessment instrument), for one of one resident reviewed for hospitalization (Resident 88). This failure had the potential to cause inaccuracy in identifying Resident 88's care and support needs, and cause delay in these needs being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the physician's order and the facility's policy and procedure, for two of two residents reviewed during medication storage inspection (Residents 192 and 51). This failure had the potential for Residents 192 and 51 to not receive the full efficacy of the medication and had the potential to place Residents 192 and 51 at risk to affect their health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided, for one of five residents reviewed for oxygen (Resident 77), when a humidifier bottle (a medical device used to increase moisture and decrease dryness from oxygen) was found undated. This failure had the potential to place Resident 77 at risk for infection and respiratory failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications (medication to manage mental and mood disorders) were necessary in managing mental illness, for one of five residents reviewed for unnecessary medications (Resident 55), when there was no evaluation or assessment by the IDT (Interdisciplinary team - a group of healthcare professionals) and psychiatrist prior to the use of risperidone (medication to treat mental illness). This failure had the potential for Resident 55 to receive unnecessary psychotropic medication and placed the resident at risk for adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory order for hemoglobin A1C (HgbA1C - blood test that shows what your average blood sugar (glucose) level was over the past two to three months) was completed as ordered, for one of five residents reviewed for unnecessary medications (Resident 53). This failure had the potential for Resident 53's blood sugar level to be uncontrolled and not be managed.

Inspectors wroteBased on observation, interview, and record review, the failed to ensure infection control measures were implemented according to the facility's policy and procedure, when: 1. The facility staff did not assess and change Resident 85's intravenous (IV- soft flexible tube placed inside a vein to give fluids or medicine) site when re-admitted to the facility. This failure had the potential to cause a life threatening infection for the resident; and 2. The facility did not report in a timely manner to the California Department of Public Health (CDPH) when the facility had a COVID-19 (coronavirus - a contagious respiratory infection) outbreak on June 8, 2024. This failure had the potential to prevent effective outbreak management that could have potentially prevented further Covid cases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate interventions were developed and implemented to address high risk for fractures (broken bones) secondary to osteoporosis (brittle bones) and history of fracture, for one of three residents (Resident A), when: 1. Further assessment and evaluation were not conducted to determine if Resident A was still a candidate for transfer using Hoyer lift (is a mobility tool for a person to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) after Resident A sustained a leg fracture on September 8, 2023 during transfer to the gerichair (a large, padded chair that is designed to help someone with limited mobility) using the Hoyer lift; and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed to include hip precautions following a right hip arthroplasty (hip replacement surgery, a type of joint replacement surgery), for one of three residents reviewed (Resident 1). This failure had the potential for the staff to not be aware of the interventions to be implemented to prevent complications related to the hip surgery of Resident 1. This failure had the potential for Resident 1 to experience post hip surgery complications (i.e. dislocation of the right hip, fracture [broken bone]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent incident of altercation between residents when the facility failed to provide one-on-one (1:1) monitoring (staff always remain with resident), for one of three residents reviewed (Resident 1). This failure had the potential to result in further incidents of altercation with other residents involving Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were implemented in the kitchen when: 1. Food items were stored in the refrigerator past the used-by date and were readily available for use; 2. One container of sugar stored in inside a plastic bag stored in the dry storage area was left open; and 3. The air gap (space between the water outlet and the flood level of a fixture) had a thick build-up of a dark black substance from the drain to the refrigerator. These failures had the potential for the growth of harmful bacteria and cross contamination that could lead to food borne illnesses for a medically compromised population of 62 residents who ate orally and received food from the kitchen out of a facility census of 65 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and treatment services were provided, for two of five residents reviewed for unnecessary medications (Residents 54 and 12), when the uncontrolled blood sugar levels were not evaluated and referred to the physician for appropriate management. This failure had the potential for Residents 54 and Resident 12 to be at risk for complications related to diabetes mellitus (abnormal blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of seven residents reviewed for nutrition (Resident 56), when, there was no assessment and further interventions to address Resident 56's continued poor food intake, including referral to the Registered Dietician (RD) and the physician. This failure resulted in Resident 56 to have a weight loss of 23 pounds (lbs)/14.02 % (percent) from February 5, 2022, to March 6, 2022 (29 days), which could subsequently cause further decline in the overall health status of Resident 56.