Coronado Ridge Skilled Nursing & Rehabilitation Ce

Inspectors wroteBased on interview, record review, and document review, the facility failed to establish and implement an enteral nutrition regimen for a resident after accepting the resident for admission, resulting in the resident receiving no enteral nutrition and only 240 milliliters (ml) of water flushes during the resident's stay at the facility for 1 of 37 sampled residents (Resident 128). The deficient practice had the potential to result in inadequate nutrition, dehydration, and avoidable decline in the resident's condition. Additional deficient practice was identified in connection with this F600 citation:Refer to F628 (Transfer and Discharge Process): [...]

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident's transfer was coordinated by failing to contact, make prior arrangements for the transfer, confirm the receiving facility agreed to accept the resident, communicate the resident's enteral nutrition needs, document the discharge process in the medical record, and provide a telephone report to the receiving facility prior to transfer for 1 of 37 sampled residents (Resident 128). The deficient practice had the potential to result in the resident transferring to a facility unprepared to receive the resident, meet the resident's care needs, and result in additional delays in receiving enteral nutrition. Additional deficient practice was identified in connection with this F628 citation:Refer to Tag F600 (Free from Abuse/Neglect): [...]

Inspectors wroteBased on interview, record review, and document review, the facility failed to verify a resident's prescribed enteral nutritional orders and ensure the necessary enteral formula was available prior to accepting the resident for admission, and after admission failed to implement an enteral nutritional regimen for 1 of 37 sampled residents (Resident 128). The deficient practice had the potential to result in delayed implementation of the resident's prescribed enteral nutrition regimen, inadequate nutritional and hydration support, compromised nutritional status, and avoidable decline. Additional deficient practice was identified in connection with this F693 citation. Refer to:Refer to Tag F628 (Discharge Process): [...]

Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence of the actions taken and follow-up made after the facility was notified of a reported positive case of Legionella (a bacteria which caused Legionnaires' disease by spreading through contaminated water mist, not water itself, which people inhale) for a resident who was discharged from the facility on 08/02/2025 and tested Legionella Polymerase Chain Reaction positive (PCR test was a laboratory technique used to detect and amplify specific genetic sequences, such as those from viruses or bacteria) at a hospital on [DATE] for 1 of 9 sampled residents (Resident 1). The deficient practice had the potential to prevent early detection and possible transmission of infection among the residents.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was initiated and completed for a resident who was admitted with a peripheral intravenous (IV) access for 1 of 24 sampled residents (Resident 3). The deficient practice had the potential to place residents at risk for not receiving IV access care.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) a clarification order was obtained for a resident's peripheral intravenous (IV) line for a newly admitted resident with no IV medication orders for 1 of 24 sampled residents (Resident 3); 2) a physician's order was followed regarding rotating sites for a peripheral IV line for 1 of 24 sampled residents (Resident 155) and 3) the facility policy was followed regarding removal of peripheral IV lines for 2 of 24 sampled residents (Residents 3 and 155). The deficient practice had the potential to place the residents at risk for phlebitis (site infection).

Inspectors wroteBased on observation, interview, document review and record review the facility failed to ensure a resident who required oxygen therapy was not connected to an empty oxygen tank and to obtain a physician's order for oxygen for 1 of 24 sampled residents (Resident 157). This deficient practice had the potential to lead to serious complications, including hypoxia, respiratory failure, and damage to vital organs.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) a physician order was obtained for moderate to severe pain medication, 2) the resident's pain was routinely monitored and 3) pharmacological and non-pharmacological pain interventions were offered and/or provided for a resident who was assessed to be at risk for pain for 1 of 24 sampled residents (Resident 154). The deficient practice had the potential to negatively impact residents' overall wellbeing.

Inspectors wroteBased on record review, document review, and interview, the facility failed to ensure a Physician Order for Life-Sustaining Treatment (POLST) form was witnessed and signed by two staff members, to validate a verbal consent for a do not resuscitate (DNR) status received from a resident's family member for 1 of 24 sampled residents (Resident 7). The deficient practice had the potential to result in a resident not receiving care consistent with their resuscitation preferences.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure the resident's pain medication was administered as ordered and appropriately managed for 1 of 5 sampled residents (Resident 1), and the pain was timely assessed for 1 of 5 sampled residents (Resident 3). This deficient practice had the potential to result in unmanaged pain, delayed relief, and decreased quality of life for the affected residents.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 4 sampled residents (Resident 1). The deficient practice potentially deprived the resident and/or resident representative of the right to be informed of the medications' risks, benefits and potential side effects.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to develop a baseline care plan for a soft collar device, an ACE wrap dressing (an elastic compression bandage typically wrapped around a sprain or strain) and CAM (controlled ankle movement) boot device for 2 of 22 sampled residents (Residents 244 and 250). The deficient practice placed the residents at risk for discomfort, skin integrity issues to affected areas and complications to surgical sites.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure documentation of application of an ordered Thrombo-Embolus deterrent (TED) stocking (stockings that help prevent blood clots and swelling in the legs) was completed for 1 of 22 sampled residents (Resident 3). The failure had the potential to adequately assess the resident's efficacy of treatment, determine resident's need for further intervention, and compliance with the physician's order.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure care and management orders were obtained, transcribed, and carried out for a soft collar device, an ACE wrap (an elastic compression bandage typically wrapped around a sprain or strain) and a boot device for 2 of 22 sampled residents (Residents 244 and 250) and a post-operative appointment was scheduled timely for 1 of 22 sampled residents (Resident 250). The deficient practice placed the residents at a potential risk for discomfort, skin integrity issues to the affected areas and complications to surgical sites.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure psychoactive medication side effects monitoring was documented for 1 of 22 sampled residents (Resident 3). The failure to document side effects of psychoactive drugs had a potential to facilitate dose adjustments if needed and the efficacy of the medication for the resident.

Inspectors wroteBased on observation, interview, record review and document review, the facility to ensure medications were secured for 1 of 6 medication carts and 1 of 22 Residents (Resident 15). The deficient practice could have jeopardized the safety of both staff and residents, as unsecured medication carts increase the risk of unauthorized access to potent medications, medication errors, theft, or misuse, posing serious health hazards and compromising the overall well-being of individuals within the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties; and for the selection of a venue that is convenient to both parties. The deficient practice had the potential to obstruct each resident's ability to make a well-informed decision about signing the arbitration agreement.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician order was obtained and care management was implemented for the use of compression stockings to treat edema for 1 of 32 sampled residents (Resident 4). This deficient practice could possibly result in inadequate treatment, increased complications, and reduced quality of life.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the correct size of an indwelling urinary catheter (Foley) was followed as ordered or clarified, and Foley care and management were transcribed in the Medication Administration Record (MAR) and implemented for 2 of 32 sampled residents (Residents 289 and 348). These deficient practices could lead to potential urinary tract infections (UTIs), an increased risk of catheter-associated complications, dehydration, blockage, and discomfort or pain for the resident.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the ordered parameters for the pain medication were followed as ordered for 1 of 32 sampled residents (Resident 8). The deficient practice could potentially result in adverse effects on Resident 8's health and well-being, compromised pain management, increased discomfort, and potential complications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a level of quaternary ammonia between 200 and 400 parts per million in the 3-compartment sink and ensure the floor sink drain was set up in a manner to prevent water splashing. The deficiency had the potential to adversely affect the ware washing process, resulting in improperly sanitized equipment and utensils that could contaminate food and cause foodborne disease to the residents.