Villa Coronado D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to facility policy and standards of practice when: 1. Kitchen Staff (KS) 1 did not perform handwashing upon entering the kitchen. 2. Kitchen Staff (KS) 2 did not clean and sanitize the thermometer probe appropriately. 3. Food items were not stored appropriately when: a. Dry storage food items were not labeled and dated. b. Canned items in the dry storage were dented and not removed from the food storage. c. Outdated/expired food items in the storage room were not discarded on or before the expiration date. These failures exposed the residents to contaminated food and unsanitary practices, which had the potential to place them at risk for developing a foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urethral catheter (UC-flexible tube which passes through the urethra and into the bladder to drain urine) was appropriately positioned for one of four sampled residents (Resident 81). This failure had the potential to result in health complications for Resident 81. Resident 81 was admitted to the facility on [DATE] with medical diagnoses including paraplegia (inability to move lower extremities) and neurogenic bladder (loss of bladder control) per the History and Physical (H & P; assessment/examination). During an observation of Resident 81 on 4/29/25 at 8:17 A.M., Resident 81's urinary drainage bag (UDB- container to collect urine) was hanging on the bedside rail, with the UC tube looped (curled) back towards Resident 81. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure effective pain management for two of four sampled residents (Resident 81 and Resident 77) when: 1. Resident 81 did not receive the prescribed medication order for severe pain. 2. Resident 77's severe pain was not reported to the physician. This failure had the potential for Residents 81 and 77 to have unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff competency when one licensed nurse (LN) 1 did not complete the required abuse training. This failure had the potential to affect residents' care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that irregularities noted by the pharmacist on the monthly regimen review (MRR) were addressed timely and documented consistently in the medical record for 1 of 30 residents (Resident 51). This failure had the potential to affect and delay interventions necessary for the resident's care and well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control practices were implemented for one of 80 residents (Resident 48) when a trash can with a hanging urine container (UC) was observed on a bedside table, close to Resident 48's tumbler (drinking cup). This failure had the potential to result in the spread of infection and cross contamination that may affect Resident 48 and/or care providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff stored and served food in a safe manner when: 1. The ice machine bin lid was open, exposing ice to potential contamination, and, 2. Breakfast trays were served to residents prior to food temperatures being documented. These failures had the potential to cause cross-contamination and expose residents to the risk of foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the prevention and spread of infection when: 1. Family members (FM) of Resident 80 were not wearing Personal Protective Equipment (PPE, special equipment such as gowns, masks and gloves designed to protect staff and patients from infection risk) while in a room requiring PPE, 2. Staff entered a resident room identified as contact precaution (preventing the spread of germs by using PPE) without wearing PPE, 3. Staff brought a medication container inside a contact isolation room and returned the unsanitized container back in the medication cart, and, 4. Staff did not perform hand hygiene (handwashing with soap and water or use of alcohol-based hand rub) before putting on gloves and removing gloves These failures had the potential to spread infection to residents, staff, and/or visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a splint was applied as ordered to one of nine residents (46) reviewed for range of motion (ROM, the movement of joints or muscles). This failure had the potential to result in a decline of Resident 46's joint mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Prevent Resident 20 from falling when a staff member did not follow a provider order, and 2. Perform an elopement (leaving facility unsupervised) assessment for Resident 78, who eloped from the facility. These failures had the potential for Residents 20 and 78 to be injured.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications given via feeding tube (a way to provide nutrition when a person cannot eat or drink safely by mouth) were administered separately for one of two residents (Resident 25) reviewed for tube feeding medication administration. As a result, there was the potential for the medications to be less effective and/or clogging of the feeding tube.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect 1 of 3 residents (Resident 1) when Resident 1 sustained an injury of an unknown origin to his left pinky finger. In addition, the certified nursing assistant (CNA) did not check on the Resident at the beginning of her shift. This had the potential to impair Resident 1's quality of life and delay in noticing any changes of Resident 1's condition. On 2/16/24, the facility reported an injury of unknown source to the Department. The report also stated that CNA 1 was suspended pending investigation. On 2/22/24 at 8 AM, an unannounced visit was conducted. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a copy of medical records in a timely manner upon request for one resident (Resident 1). As a result, Resident 1 did not receive a copy of the medical records requested.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Sterile water for irrigation were dated when opened, 2. Discontinued medications were disposed from the medication cart. 3. Unattended medication cart was securely locked These failures had the potential for unsafe storage and administration of resident medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when: 1. Licensed Nurse (LN) 41 did not disinfect the vitals machine equipment between residents (42 and 46), 2. LN 42 did not sanitize a glucometer after used before keeping in the supply box, 3. LN 43 did not change gloves while in contact with dirty and clean equipment and supplies, and, 4. Emergency medical technicians (EMTs) did not wear personal protective equipments (PPE) during a resident transfer from gurney to bed. These failures had the potential to spread infections between residents, staff, and visitors.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and homelike environment when linen carts were stored outside of a resident's room for one of two residents reviewed for environment (Resident 3). This failure had the potential for a decreased quality of life for Resident 3 and his family.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment tool) was accurately coded for one of 18 residents (Resident 63) reviewed for accurate MDS. This failure had the potential for Resident 63 to receive inappropriate care due to inaccurate diagnosis.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan related to pressure ulcers (an injury to skin and tissue usually caused by pressure) for one of eight residents reviewed for pressure ulcers (Resident 59). This failure had the potential for poor communication among care providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a resident care plan related to communication for one of 18 residents (Resident 63). This failure had the potential for Resident 63's specific care needs and interventions to not be communicated and addressed by healthcare professionals. Findings. A review of Resident 63's admission Record indicated that Resident 63 was admitted to the facility on [DATE] with diagnoses Status Post Motor Vehicular Accident, Subarachnoid Hemorrhage, (a bleeding in the space between the brain and the tissue covering the brain) and Traumatic Brain Injury (Brain dysfunction caused by an outside force, usually a violent blow to the head). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin assessment and wound treatment to one of three residents (Resident 47) when Resident 47's eschar (dead tissue) was not assessed and treated per physician's orders. This failure had the potential to worsen the condition of Resident 47's wound, with the potential of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide treatment for pressure ulcer (skin injury due to pressure) prevention to two of eight residents (Residents 17, 59). This failure had the potential for Residents 17 and 59 to develop pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure two of 18 sampled residents (Residents 1, 31) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: a. Non-pharmacological intervention that is specific for Resident 1's behavior was not implemented. b. Resident 31's as needed Lorazepam (medication used to treat anxiety) was administered beyond the 14 days ordered. c. There was no documentation of the rationale for extending Resident 31's as needed Lorazepam. 2. Monitor for the appropriate indication for the use of a psychotropic medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater. An observation of 27 opportunities during the medication pass resulted in four errors when: 1. A licensed nurse (LN) 11 did not flush a gastronomy tube (G-tube, a tube that is surgically placed into the stomach to deliver food and medication) between medications during administration. 2. A licensed nurse (LN) 12 did not ensure residual (remaining crushed medication) for three crushed medications were rinsed from the medication cups and administered to Resident 20. The calculated medication error rate was 14.81 percent. These failures placed the health and safety of all residents at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen trash cans were cleaned and sanitized. This failure had the potential to place residents at risk for foodborne illness from cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medical record related to communication was accurate for one of one residents (Resident 63) reviewed for communication. This failure had the potential for Resident 63 plan of care to not be communicated amongst healthcare providers.