Coronado at Stone Oak

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 observed for food service sanitation and safety, in that:During the initial tour on 7/14/26:---The facility failed to ensure 3 portion plates and 4 baking pans were not upside down with food contact surfaces exposed. ---The facility failed to ensure an open box of Cream of Wheat was not on top of a warm oven. ---The facility failed to ensure 2 containers of soup base were not opened and not refrigerated as recommended on the labels. ---The facility failed to ensure there was not an unsecured overhead cover in the pantry. ---The facility failed to ensure the walk-in-refrigerator did not have an opened bag of (1) ham and salad container with an expiration date of 7/12/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be treated with respect and dignity and to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 8 residents (Resident #12) reviewed for dignity. The facility failed to ensure Resident #12 was provided with his preference for grooming/shaving of his facial hair for a period of 6 days. This failure could result in residents experiencing a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one of eight residents (Resident #90) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light in Resident #90's room was placed in a position accessible to the resident on 7/15/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #130) reviewed for an indwelling catheter. The facility failed to ensure Resident #130's indwelling catheter was attached to prevent pulling or tugging on the perineal area. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #3) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #3 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN . This deficient practice could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 2 of 5 (Resident #6 and #104) reviewed residents' refrigerators. The facility failed to ensure Resident #6 did not have an unlabeled, undated container of watermelon pieces in her personal refrigerator on 7/16/2026. The facility failed to ensure Resident #104 did not have unlabeled, undated, opened cheese dip container in her personal refrigerator on 7/14/2026. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food.

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 1 of 8 residents (Resident #2) reviewed for sanitary environment, in that: The facility failed to ensure on 7/15/26 Resident #2's catheter bag was hanging on the bed rail and not attached to a waste basket. This failure could result in the spread of disease and expose residents with catheters to infections and a diminished quality of life. Record review of Resident #2's face sheet, dated 7/15/26, reflected a [AGE] year-old male, with an admission date of 6/16/26 with diagnoses that included urinary tract infection (primary) and type 2 diabetes mellitus. The RP was listed as self. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for medical records. 1. The facility failed to ensure Resident #1's ADL-Bathing record recorded a bath or refusal for 1/19/2026, as noted on the electronic medical record. 2. The facility failed to ensure Resident #2's ADL-Bathing record recorded a bath or refusal for 1/2/2026 and 1/19/2026, as noted on the electronic medical record. 3. The facility failed to ensure Resident #3's ADL-Bathing record recorded a bath or refusal for 1/26/2026, as noted on the electronic medical record. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #4) reviewed for quality of care. The facility failed to notify the physician when Resident #4 gained 3 pounds over night between the dates of 1/19/2026 and 1/20/2026) per the orders and facility policy. This failure could place residents at risk of harm, not receiving necessary medical care, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure correct use of bed rails and to assess the resident for risk of entrapment from bed rails for 3 of 6 Residents observed for the use of side rails (Resident #1, Resident #13 and Resident #340). 1. Nursing staff failed to obtain an informed consent and assess Resident's #1 for the use of 1/4 side rails. 2. Nursing staff failed to obtain an informed consent for Resident #13 for the use of 1/4 side rails. 3. Nursing staff failed to obtain an informed consent and to assess Resident #340 for the use of 1/4 side rails. These deficient practices could affect any resident with bed side rails and could cause avoidable accidents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide an assessment that accurately reflected the resident's status for 1 (Resident #26) of 32 residents reviewed for assessment accuracy. The facility failed to reflect Resident #26 used a Bipap machine (bilevel positive airway pressure device or Type of respiratory support therapy that uses positive air pressure to help individuals breathe, especially individuals who have sleep apnea (a condition that affects breathing at night) or other respiratory conditions) machine on her admission MDS. This failure placed Residents at risk of having inaccurate assesments to include those who need a bipap machine at night, that could lead to Residents careplan not being correct and Resident not recieving care as needed.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #26) of 32 residents reviewed for comprehensive care plans. The facility failed to reflect Resident #26 used a Bipap machine (bilevel positive airway pressure device or Type of respiratory support therapy that uses positive air pressure to help individuals breathe, especially individuals who have sleep apnea (a condition that affects breathing at night) or other respiratory conditions) machine and Resident #26's shortness of breath diagnosis was not reflected on her comprehensive care plan. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one Resident (Resident #294) of 4 Residents reviewed for pressure sore management. 1. LVN C failed to document an accurate skin assessment for Resident #294 on 05/08/2025. This failurecould place Resident at risk on not recieving appropriate care leading to worsening of skin condition.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 resident (Resident #293) of 32 residents reviewed for safe environments. The facility failed to ensure Resident #293 did not have flammable materials near her oxygen. This deficient practice places residents on oxygen therapy at risk for burns.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (Resident #26) out of 3 residents observed for respiratory therapy. The facility failed to obtain physician orders for Resident #26's Bipap she used each night at the facility since her admission on [DATE]. This failure place residents who reside at the facility at risk for inaccurate care and communication of health conditions to other providers.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents were seen by a physician at least at least once every 60 days for 2 of 6 Residents (Resident #2 and Resident 92) whose records were reviewed for physician visits. 1. The facility failed to ensure Resident #2's primary care physician met with Resident #2 as required. 2. The facility failed to ensure Resident #92's primary care physician met with Resident #92 as required. This deficient practice could affect any resident and could contribute to the resident's medical needs not being addressed or met.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to provide pharmaceutical services to administer drugs and biologicals that meet the needs of each resident for 2 of 5 medication carts (Cart #1 and #2 on 800 hall) observed and for 1 of 2 medication rooms ([NAME] Hall) observed. 1. The facility failed to remove expired medications from medication cart #1 and medication cart #2 on the 800 hall. 2. The facility failed to remove expired medication from the medication room on the [NAME] hall. These failures could place residents at risk of decreased therapeutic response and illness from expired medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (Residents #26 and #293) of 32 residents observed for medication safety and security. 1. The facility failed to store Resident #26's Flonase (allergy nasal spray) in the medication cart and the medication was left on Resident #26's bedside table. 2. The facility failed to store Resident #293's Flonase (allergy nasal spray) in the medication cart and the medication was left on Resident #293's bedside table. These failures could result in , access to medications by unauthorized persons, and could result in decreased health response or misuse of medication.

Inspectors wroteBased on observation, interviews and record reviews, 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 1 resident (Resident #294) of 32 residents reviewed for EBP. The facility failed to establish EBP for Resident #294 when she had an open sacral wound with a dressing. This facility failure affects residents with open wounds, or other requirements for EBP, and could result in MDRO contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 15 residents (Residents #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure Resident #1's physician's orders dated 02/27/25 were updated to include the resident no longer received wound treatment to a stage 2 wound to her sacrum (triangular bone on the lower back) to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. 2. The facility failed to ensure Resident #2's physician's orders dated 01/24/25 were updated to include the resident no longer received wound treatment to DTI area to his left heel to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Residents #1) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #1's eMAR reflected when she received oxycodone as follows: [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety for 1of 2 (Willow Unit) nutrition rooms reviewed for storage: 1. The refrigerator on [NAME] Unit had a red sticky substance from spilled liquids on the shelves, on the door, and on the bottom shelf where nutritional supplements were stored for the residents. 2. The freezer on [NAME] Unit had food particles and stains from spilled liquids which had dried, a strand of hair on the floor of the freezer compartment where there were packages of food stored. 3. The ice machine on [NAME] Unit had a large amount of white hard water stains that had come from the vent of the ice maching and a black residue on the inside above the ice on the outlet where ice is dispensed into the unit. [...]

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for 1 of 8 Residents (Resident #1) whose records were reviewed for abuse. The ADM failed to report an allegation of resident abuse within 2 hours after learning about the allegation per facility policy. This deficient practice could affect any resident and contribute to further resident abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for 1 of 8 Residents (Resident #1) whose records were reviewed for abuse. The ADM failed to report an allegation of resident abuse within 2 hours after learning about the allegation per facility policy. This deficient practice could affect any resident and contribute to resident abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical and nursing needs including the services to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 of 8 Residents (Resident #67) whose records were reviewed for care plans. Nursing staff failed to care plan Resident #67's skin conditions including autoimmune disease (Conditions where the immune system mistakenly attacks healthy body cells)-induced wound to left forearm, autoimmune disease-induced wound to left leg and autoimmune disease-induced wound to left forearm. This deficient practice could affect any resident and contribute to residents not receiving care and services as needed for skin conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 1 Resident observed for mechanical lift transfer. CNA I failed to apply the brakes and widened the legs on the mechanical lift when raising Resident #8 into the air and transferring him from the bed to the wheelchair. CNA I also turned the mechanical lift towards the motorized wheelchair by pulling on the sling because there was not enough space for her to maneuver the lift around the foot of the bed and in between the metal shelving unit in front of the foot board. These deficient practices could affect residents who used a mechanical lift for transfers, could cause avoidable falls and residents could sustain serious injuries from a fall from a mechanical lift.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the bed's dimensions are appropriate for the resident's size and weight for 1 of 8 Residents (Resident 8) whose records were reviewed for the use of side rails. The facility failed to ensure the size of the mattress was compatible with the bed frame resulting in a significant gap between the mattress and the side rails. This deficient practice could affect any resident using a side rail and could result in avoidable injury to the resident.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a Comprehensive Assessment for 1 of 4 (Resident #22) residents for MDS review. The facility failed to do a Comprehensive Assessment upon admission for Resident #22 who was admitted to the facility for respite while on hospice. This deficient practice could contribute to the resident not receiving the care and services needed.