Coronado Care Center

Inspectors wroteBased on observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items stored in facility's freezer were labeled and dated. This deficient practice is likely to affect 76 residents listed on the resident census list provided by the Administrator on 06/09/25 and could likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 5 (R #2, R #23, R #54, R #56 and R #75) of 5 (R #2, R #23, R #54, R #56 and R #75) residents reviewed when staff failed to: 1. Update R #2's care plan to include the use of a trapeze bar (a short horizontal bar that is suspended from two ropes) for mobility. 2. Update R #23's and R #54's plan of care to include hospice (care and services for people nearing the end of life). 3. Update R #56's care plan to remove the use of a communication board (a tool used to help people with limited language skills or who are nonverbal to communicate) with word cards. 4. Update R #75's plan of care to include advanced directive. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed 3 medication errors out of 29 opportunities for 3 (R #39, R #43, R #76) of 4 (R #36, R #39, R #43, R #76) residents reviewed during medication administration. This resulted in a medication error rate of 10.34%. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance.

Inspectors wroteBased on observation and interview, the facility failed to ensure the hallway was accessible for residents. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #48) of 1 (R #48) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.

Inspectors wroteBased on record review, observation and interview, the facility failed to keep residents free from physical restraints for 1 (R #8) of 1 (R #8) resident observed during random observations. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity.

Inspectors wroteBased on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #23) of 1 (R #23) resident reviewed for MDS assessment timing. This deficient practice could likely result in the residents not receiving the appropriate care and services they need.

Inspectors wroteBased on observation and interviews, the facility failed to maintain proper infection prevention practices for 3 (R #39, R #43, and R #76) of 4 (R #36, R #39, R #43, and R #76) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents.

Inspectors wroteBased on record review and interview, the facility failed to provide documentation confirming one Nurse Aide (NA), employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 68 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the dry storage area were stored properly. 2. Ensure all food items in the walk-in refrigerator were labeled and dated. 3. Ensure all food items in the freezer were sealed appropriately. This deficient practice is likely to affect all 75 residents identified on the resident census list provided by the Director of Nursing on 05/13/2024. These deficient practices are likely to expose residents to food borne illnesses.

Inspectors wroteBased on interview and observation, the facility failed to: 1. Ensure the facility had enough food to serve all residents the meal on the menu. 2. Ensure staff served residents a second portion of meal if requested. This deficient practice is likely to affect all residents who eat at the facility. If the facility fails to provide adequate food to meet the nutritional needs of the residents then residents are likely to lose weight and not get their nutritional needs met.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #13) of 1 (R #13) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were invited to attend care plan meetings for 2 (R #23 and R #30) of 2 (R #23 and R #30) residents reviewed for participation in care planning. If residents are not able to participate in their care plan development, then residents could likely not get the care and treatment they want or need.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who was admitted with an indwelling Foley (name of device) catheter (a thin, sterile tube inserted into the bladder to drain urine) was assessed for the removal of the catheter for 1 (R #46) of 1 (R #46) sampled residents with an indwelling urinary catheter. This failed practice is likely to cause R #46 to not regain bladder control, to develop bladder incontinence, or to develop a bladder infection.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an adaptive eating device (a tool that helped a person with a disability do a certain task) for 1 (R #35) of 1 (R #35) residents reviewed during dining observation. If residents are not provided adaptive eating devices as needed, then residents might be unable to consume their meals and beverages and likely to have weight loss, malnutrition, and dehydration.

Inspectors wroteBased on record review, observation, and interview the facility failed to 1) Develop a comprehensive care plan and 2) Implement a comprehensive care plan for 4 (R #2, 30, 31 and 41) of 4 (R #2, 30, 31 and 41) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being.

Inspectors wroteBased on observation, record review and interview, the facility failed to store food under sanitary conditions by not ensuring (1) Food items stored in facilities dry storage were labeled and dated, (2) Food items in the dry storage area were stored in the correct locations, and (3) expired foods were either used or discarded prior to expiration date. These deficient practices are likely to affect all 61 residents residing in the facility, and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and comfortable homelike environment in the dining area. This failure has the potential to affect the 54 residents that choose to eat in the main dining facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate pain relief for 1 (R #41) of 1 (R #41) resident reviewed for pain. This failure could likely result in unrelieved pain and diminished quality of life for the resident.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that the mental health needs of 1 [R #31] of 1 [R #31] resident reviewed for mental health needs was assessed and care was offered/provided to ensure their highest practicable well being. This deficient practice is likely to negatively impact the health and well being of residents.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide meals that tasted good, and served at an appetizing temperature (at or above 135 degrees Fahrenheit) for 2 (R #38 and R #164) of 2 (R #38 and R #164) residents reviewed for food quality. This failed practice has the potential to affect all residents identified on the resident census list provided by the administrator on 05/12/23 that were able to eat meals from the kitchen. This deficient practice has the potential for residents to not want to eat meals, which could lead to significant weight loss and not meeting their highest level of well-being.

Inspectors wroteBased on observation, interview and record review the facility had the responsibility to implement standard precautions (infection control practice to limit or eliminate the spread of infections). The facility failed to investigate, recognize, prevent, and maintain control of the spread of infection to (24 of 61) residents. Failure to adhere to an infection control program is likely to cause the spread of infections to and from residents within the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that residents have the ability to directly contact caregivers from their rooms/toilet areas from a communication system for 5 (R #36, 41, 49, and 50, and 55) of 5 (R #36, 41, 49, and 50, and 55 ) residents reviewed for an equipped call light system. If the facility is not ensuring that residents have access to request assistance from their room or bathrooms, then residents may not get the care and services they need.

Inspectors wroteBased on observation and interview, the facility failed to provide sufficient space for Dining. This failure has the potential to affect the all residents (as listed on the Resident Census provided by the Administrator on 05/08/23) living in the facility, and is likely to hinder safe movements, timely delivery of meals, and exceed acceptable noise levels while in the dining area.

Inspectors wroteBased on record review, observation, and interview, the facility failed to timely revise and update a care plan for 1 (R #49) of 2 (R #31 and R #49) residents reviewed for pain. This deficient practice could likely cause staff to be unaware of current resident needs and impair the safety of residents.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide trauma informed care (care to help prevent furtherance of trauma and promote safety and well-being) to 1 (R #31) of 1 (R #31) resident diagnosed with a trauma incident. Failing to provide care and seek out knowledge of triggers is likely to cause the resident to become secluded (withdrawn), exhibit behaviors, or cause self harm.

Inspectors wroteBased on observation and interview, the facility failed to ensure that pharmaceutical services for 1 (R #48) of 1 (R #48) resident reviewed for accurate dispensing and administration was correct. The pharmacy placed multiple orders for the medication on the same package creating confusion. This failure could cause a potential overdose of R # 48.