Coronado Healthcare Center

Inspectors wroteBased on observation, clinical record review, interviews, facility documentation, and policy, the facility failed to ensure wound care treatments were provided according to professional standards of practice and provider orders for one resident (#4) out of three sampled residents. The universe was 165. This deficient practice placed residents at risk for infection.

Inspectors wroteBased on a review of the clinical record, staff interviews, and a review of policies and procedures, the facility failed to update and revise care plans for two residents (Residents #21 and #56). The deficient practice can result in inaccurate monitoring of a resident's medical conditions and care, which are necessary to achieve the resident's health and well-being goals. The universe was 180. Findings Includes: Regarding Resident #21: Resident #21 was admitted to the facility on [DATE], with diagnoses of multiple sclerosis, bipolar disorder, anxiety disorder, and cognitive communication deficit. The Minimum Data Set (MDS) dated [DATE], revealed the resident had limited range of motion in the lower extremities and was dependent on staff for toileting hygiene, bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. [...]

Inspectors wroteBased on observations, facility documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to provide an ongoing program of activities designed to meet the interest and the physical, mental, and psychological well-being of one resident (Resident #15). The sample was three residents and the universe is 191 residents. The deficient practice could result in a decline in physical, mental, and social skills.

Inspectors wroteBased on a review of the clinical record, staff interviews, and a review of policies and procedures, the facility failed to ensure that the physician's orders were implemented per professional standards for one resident (Resident #56). The deficient practice can result in inaccurate monitoring of a resident's medical conditions and care, which are necessary to achieve the resident's health and well-being goals. The universe was 180.

Inspectors wroteBased on staff interviews, observations, and review of facility policies and procedures ,the facility failed to ensure food was stored within appropriate guidelines. The deficient practice could increase the risk for foodborne illness. The facility census was 191 and the survey sample size was thirty-five. During the initial kitchen observation conducted on January 27, 2026 at 8:21am, food debris was noted in the dry storage area, under the bottom shelf. It appeared to dry, crumblike items. The dietary manager #42 also observed the debris and stated that it could possibly draw vermin to the area. He also stated that their procedure is that dishwashing staff are responsible for sweeping and mopping all floors after every meal, including this dry storage area. During this same initial tour, the refrigerator was observed and the following items noted: [...]

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident's (#30) rights were honored with notification of changes of condition to the resident's legal guardian. The deficient practice could result in a legal guardian not being aware of a resident's condition, and unable to participate in medical decision-making on behalf of the resident.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#10) was provided care regarding wound care treatments.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#4) was provided treatment and services according to professional standards regarding following a physician order regarding care of an intravenous (IV) site. The deficient practice could lead to infection of an IV site. -Findings Include: Resident #4 was admitted to the facility May 7, 2025, with diagnoses that included staphylococcal arthritis of right hand, methicillin susceptible staphylococcus aureus infection, cellulitis of right upper limb, and cutaneous abscess of right hand. A physician order dated May 7, 2025, indicated for central line and midline care: change all central line, PICC, and midline transparent dressings per sterile technique upon admission, every 7 days, and as needed for wet, loose, or soiled. [...]

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure infection control policies were followed for one resident (#4) regarding Enhanced Barrier Precautions (EBP). The deficient practice could lead to the spread of infection. -Findings Include: Resident #4 was admitted to the facility May 7, 2025, with diagnoses that included staphylococcal arthritis of right hand, methicillin susceptible staphylococcus aureus infection, cellulitis of right upper limb, and cutaneous abscess of right hand. A physician order dated May 8, 2025, indicated for enhanced barrier precautions: personal protective equipment (PPE) required for high resident contact care activities, with an indication of wounds and a central line. [...]

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy the facility failed to ensure that one resident (#1) was free from sexual abuse. The deficient practice has the potential for further abuse resulting in harm to residents.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy the facility failed to ensure that an allegation of sexual abuse for one resident (#1) were reported timely to the State Agency. This deficiency practice could result in the appropriate State agencies not being notified of allegations of abuse as required. Review of the facility's investigation report noted an interview with a Certified Nursing Assistant (CNA/staff #52). The CNA (#52) reported that on the evening of 1/21/2024, she saw resident #1 bent over with resident #2 standing behind her. Both residents had their pants and briefs pulled down. The staff separated residents and reported what she saw to a nurse (staff #34). Review of a surveillance video footage from 1/21/2024 of the hallway outside resident #1's bedroom showed resident #1 and resident #2 enter resident #1's room at 8:27 p.m. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of the facility policy and procedures, the facility failed to ensure one resident (#465) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (# 613) had a reconciliation of post-discharge medications according to professional standards. The deficient practice could result in unsafe discharges for residents.