Corona Regional Medical Center D/P SNF

Inspectors wroteBased on dietary observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. Serving pans did not air dried before stacked and stored.2. Two Cooks with facial hair did not wear hair restraint while preparing meals.3. Dust found on the rack and above walk in freezer.4. Grime buildup found on several pieces of equipment.5. Several food items found in kitchen were not properly labeled.6. Expired beverages found in Annex Resident's refrigerator. These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 6 out of 60 sampled residents who received foods from the kitchen.1. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure timely maintenance of equipment when:1. Rust found on the rack in the kitchen.2. Five worn out cooking pans found in kitchen. These failures had the potential to cause cross contamination to a population 6 out of 60 sample residents who received food from the kitchen.1. According to the Federal Food Code 2022, the Food Code indicates, Food-contact surfaces and utensils are to be clean to sight and touch. Utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring and decomposition. On June 2, 2026, at 10:20 a.m., a concurrent observation and interview were conducted with the Director of Food Services (DFS) and [NAME] (CK) 1 in the kitchen at cook area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for one of four residents (Resident 34) when nursing staff did not administer pantoprazole (used to treat stomach acid) in accordance with the manufacturer's instructions. This failure had the potential to result in Resident 34 not receiving the full benefit of the medication, leading to further health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided, for one of 15 sampled residents (Resident 60) when midodrine (medication used to treat low blood pressure) was not administered according to the physician's order. This failure had the potential for a delay in care and treatment and could have caused a decline in the resident's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a visitor was observed in the room of Resident 8, who was on isolation for contact precaution for Candida Auris (C. Auris - a highly contagious and multidrug resistant fungus), not wearing personal protective equipment (PPE- specialized clothing or equipment worn to create a barrier between healthcare workers and potential sources of infection, like blood, body fluids, or other potentially infectious materials). This failure had the potential to spread Candida Auris to the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed for two of three residents, Residents 1 and 2, when:Resident 1 did not have hand rolls in her left and right hands; andResident 2 did not have a left elbow splint. These failures had the potential to result in Residents 1 and 2 having skin impairments and further decline in range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medications were administered within 60 minutes of their scheduled times for one resident, Resident 3. This failure had the potential to result in decreased effectiveness of Resident 3's medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the patients' rights were protected, specifically the right to have their designated representative informed of significant events or changes, for one of three residents reviewed (Resident 1), when the facility did not notify Resident 1's representative of the change in the prescription medication Tylenol #3 (acetaminophen-codeine, pain medication) to the prescription medication tramadol (pain medication). This failure prevented the residents' representative from participating in decisions related to the residents' care and well-being as authorized.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Comprehensive Minimum Data Set (MDS - standardized assessment tool used to evaluate clinical, functional, and psychosocial status of all residents) Assessment accurately reflected the residents' current status for one of three residents reviewed (Resident 1), when discrepancies were found in Resident 1's Quarterly Comprehensive MDS Assessment. This failure had the potential to lead to inappropriate care planning for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident with a non-pressure related skin impairment received appropriate treatment and services in accordance with professional standards of practice for one of three residents reviewed (Resident 1), when the CNA (certified nurse assistant) failed to identify and report a left abdominal fold skin tear to the wound care nurse, resulting in a delay in treatment and increased risk of infection. This failure had the potential to cause a negative outcome in Resident 1's physical health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Interdisciplinary Team (IDT - a collaborative group of diverse healthcare professionals who work together to create and implement a unified, comprehensive care plan for a resident) notes accurately reflected the residents' current status for one of three residents reviewed (Resident 1), when discrepancies were found in Resident 1's IDT Notes. This failure had the potential to lead to improper care planning and inaccurate communication between disciplines.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided meet professional standards of practice, for one of one resident reviewed (Resident 39), when the Licensed Vocational Nurse (LVN) did not check the NGT (nasogastric tube - a flexible tube inserted through the nose and down the throat into the stomach) placement prior to medication administration. This failure had the potential for Resident 39 to develop aspiration pneumonia (a lung infection that occurs when food, liquid, or objects are inhaled into the lungs causing inflammation and fluid build-up).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 vials of Ativan (medication used to treat anxiety disorders) two (2) mg (milligram - a unit of measurement) was not stored beyond the manufacturer's recommended discard date during an inspection of the medication refrigerator in the medication storage room located in the main building. This failure had the potential for a resident to receive an expired and ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to a vulnerable facility population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practice was implemented when the Licensed Vocational Nurse (LVN) did not properly clean and disinfect shared glucometer (measures the amount of glucose [sugar] in the body) in accordance with the disposable wipe manufacturer's specified contact time (contact time/wet time - amount of time a disinfectant needs to stay visibly wet on a surface to effectively kill germs). This failure had the potential to expose the resident to cross-contamination and development of infection.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions of turning and repositioning of dependent residents, for one of four residents (Resident 1), who had the potential for the development of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed the resident at an increased risk for developing and/or worsening of pressure injuries.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time Registered Dietitian and/or a full-time Director of Food Services in accordance with California Code, Health and Safety Code - HSC § 1265.4 The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in inadequate supervision leading to food borne illness for seven residents who received food from the kitchen out of a facility census of 58.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. The Director of Nutritional Services and the Nutritional Service Manager did not instruct food service workers to follow manufacturer guideline for monitor temperature on dish machine. 2. The cook used wrong scoop plated lunch meal on February 13, 2024, for four residents (Residents 2, 19, 30, and 54). (Cross reference 803) These failures had the potential for unsafe food practices which may lead to foodborne illness (stomach illness acquired from ingesting contaminated food), and the potential to not meet the nutritional needs of the residents in a medically vulnerable population of seven out of 58 sample residents who received food prepared in the kitchen. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of five residents (Residents 2, 19, 30, and 54), was met for lunch, when the meal was not plated in accordance with menu guidance for lunch. This failure had the potential to result in under or over nutrition. When a resident receives foods that are not consistent with their physician ordered diet, it may result in further compromising the resident's medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when : 1. The Prep sink did not have an air gap; 2. Nine cutting boards surface were heavily marred; 3. Three storage silver shelves in trayline area had rust; 4. Two microwaves in the kitchen were dirty; 5. Lacked temperature monitor for Prep table refrigerator; 6. Multiple areas in the kitchen were covered with dust; 7. The walk in refrigerator's gasket was wore out; 8. Unsanitary storage condition in walk in refrigerator; 9. Multiple areas in the kitchen's floor did not have smooth surface; 10. Trash were found in the multiple areas in the kitchen; 11. Build up grease and black/brown debris found on fire suppression unit above stove and fryer; 12. Cobweb found in dry storage room; and 13. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when trash was found on the ground surrounding the trash compactor, and the trash was piled up above the fill rim of the trash compactor. This failure had the potential to attract rodents and insects which could place residents at risk for cross contamination (the process by which bacteria are unintentionally transferred from one substance or object with harmful effect) and foodborne illness (illnesses cause from ingestion contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for the monitoring of resident's edema (a swelling caused by too much fluid trapped in body's tissues) for one of one resident reviewed (Resident 161). This failure resulted in Resident 161's edema not being assessed by licensed staff from February 10, 2024 to February 12, 2024, which increased the potential for Resident 161 not to receive the proper care and treatment timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the enteral formula (EF - a form of nutrition that is delivered into the stomach as a liquid) was labeled with the date and time for one of six residents (Resident 45) receiving enteral formula. This failure had the potential for Resident 45 to experience complications from the formula, such as nausea, diarrhea, or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control prevention when Registered Nurse (RN) 3 did not wear gloves while handling a gastrostomy tube (G-tube - a tube inserted into the stomach to provide nutrition) for one resident (Resident 38). This failure had the potential to expose the vulnerable resident to infection.

Inspectors wroteBased on interview, and record review, the facility failed to follow the responsible party's declination for the COVID-19 vaccine for one of three residents, (Resident 1). This failure denied Resident 1's responsible party, (RP) to exercise her rights on behalf of Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of abuse, to the state survey agency, ombudsman, and local law enforcement, within two hours for one of three residents (Resident 1). This failure had the potential to result in the delay of investigation and implementation of corrective action for Resident 1.