Inspection Reports for
Corona Health Care Center

The facility was generally compliant with licensing requirements, with pathways clear, equipment and furnishings in working order, and proper storage of medications and supplies. One deficiency was cited related to facility staff writing the start date of medications on prescription labels, which posed a potential health and safety risk.

The inspection found the facility generally compliant with licensing standards, including safe storage of medications and proper facility maintenance. One deficiency was cited related to staff writing the start date on prescription labels, which posed a potential health and safety risk.

The investigation was complaint-driven, focusing on allegations of delayed medical follow-up, inadequate skin monitoring, unsafe care practices leading to falls, improper storage of smoking materials, and inadequate pain management. The findings substantiated these complaints with evidence of delays, omissions, and unsafe practices.

The facility failed to ensure timely neurology follow-up for Resident 85, failed to identify and notify the physician about multiple skin discolorations for Resident 10, failed to provide two-person assistance during care resulting in a fall and fracture for Resident 24, improperly stored smoking materials for Resident 57, and failed to accurately assess and manage pain for Resident 24.

The facility was found deficient in multiple areas including failure to provide advance directive information, improper discharge procedures, inadequate follow-up care, medication administration errors, unsafe medication storage, infection control lapses, and food safety violations.

The complaint investigation was substantiated. Resident 1 reported unauthorized transactions on his debit card by the Social Service Designee, who admitted to the misuse and agreed to repay the resident. Resident 1 expressed no desire for legal action as long as the money is returned.

The facility failed to protect Resident 1 from misappropriation of property when the Social Service Designee used the resident's bank card for personal purchases without consent. The SSD admitted to owing the resident approximately $2300 and agreed to repay the amount, with partial payment already made.

The investigation found discrepancies in the dates of Resident #1's fall and a delay in seeking medical attention after the fall, which posed an immediate health, safety, and personal rights risk to the resident. A Type A deficiency was issued for failure to ensure immediate medical attention.

The investigation found discrepancies in the reported dates of Resident #1's fall and noted a delay in seeking medical attention after the fall, posing immediate health, safety, and personal rights risks to the resident. A Type A deficiency was issued for failure to ensure immediate medical attention.

The complaint investigation was triggered by allegations that staff did not reappraise a resident as necessary and that the facility did not have enough staff to meet resident needs. The investigation included file reviews and interviews and concluded the allegations were unsubstantiated due to insufficient evidence to prove violations.

The investigation found that Resident #1 sustained an ankle fracture and subsequent fall, but there was insufficient evidence to substantiate that staff neglect caused the resident's death. The allegations that staff did not reappraise the resident as necessary and that the facility lacked sufficient staff were both unsubstantiated due to lack of preponderance of evidence.

The complaint was substantiated. The allegation that staff did not ensure a resident received medical and dental services was validated by evidence including interviews with the resident, public guardian, staff, and record reviews.

The investigation found that a resident (R1) had not received dental care since moving into the facility in 2017 due to lack of assistance and a plan to encourage routine dental care. The allegation was substantiated based on interviews, record reviews, and evidence that R1's mental health condition impaired self-advocacy and the facility failed to provide adequate support for dental care.

The complaint investigation was triggered by allegations that staff did not reappraise the resident as necessary and that the facility did not have enough staff to meet resident needs. The allegations were found unsubstantiated after investigation.

The investigation found that the allegations of resident death due to staff neglect and insufficient staffing to meet resident needs were unsubstantiated due to lack of preponderance of evidence. The resident had an ankle fracture and required two-person transfer, but staff response to a call light was insufficient, though no conclusive neglect was established.

The complaint was substantiated based on evidence including interviews with the resident, public guardian, staff, and review of records. The resident had not seen a dentist since moving in 2017, and the facility did not provide adequate assistance for dental care despite the resident's mental health condition limiting self-advocacy.

The investigation found that staff did not ensure that a resident received dental services since moving into the facility in 2017. The resident has a mental health condition that impairs their ability to advocate for their own care, and the facility lacked a plan to encourage routine dental care and provide assistance in obtaining such care. The allegation was substantiated.

The visit was complaint-related, investigating issues with dietary services, infection control, and environmental safety. The complaints were substantiated based on observations and interviews.

The facility failed to properly clean and sanitize the ice machine and its components, resulting in contamination risks for 87 of 90 residents. Additionally, shared devices such as a pill crusher and stand lift machine were found unsanitary. The fire door closer was dismantled, and the ceiling above it showed water damage, creating safety hazards for residents.

The facility was found to have multiple deficiencies including lack of physician orders for half bed rails for two residents, expired food handler certifications for two kitchen staff, incomplete resident medical and care plans, and failure to assist residents with medications as required. A civil penalty was issued for repeated violations within 12 months.

The inspection found multiple deficiencies including lack of physician orders for half bed rails for two residents, expired food handler certifications for two kitchen staff, incomplete resident medical and care documentation, and failure to assist residents with medications as ordered. Some deficiencies were dismissed, but others resulted in citations and a civil penalty.

The complaint investigation was triggered by allegations that the licensee did not ensure facility grounds were free from hazards, staff did not adequately supervise a resident resulting in injury, staff did not provide timely assistance, and staff did not ensure medication administration as prescribed. The first three allegations were unsubstantiated, while the medication administration allegation was substantiated.

The investigation found the first three allegations regarding hazards on facility grounds, supervision, and timely assistance to residents to be unsubstantiated based on interviews and observations. However, the allegation that staff did not ensure residents were administered medications as prescribed was substantiated due to multiple medication administration record (MAR) discrepancies and missing medication administrations for Resident #1.

The complaint investigation was triggered by allegations that the licensee did not ensure facility grounds were free from hazards, staff did not adequately supervise residents resulting in injury, staff did not provide timely assistance, and staff did not ensure residents were administered medications as prescribed. The first three allegations were unsubstantiated, while the medication administration allegation was substantiated.

The investigation found the first three allegations regarding hazards on facility grounds, supervision, and timely assistance to be unsubstantiated based on interviews and observations. However, the allegation that staff did not ensure residents were administered medications as prescribed was substantiated, with evidence of multiple missed medications and incomplete medication records for Resident #1.

The investigation was complaint-driven, focusing on fall risk identification failures and medication reconciliation issues. The complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to implement a system to identify and monitor fall risk residents, resulting in recurrent falls. Additionally, the facility failed to ensure accurate reconciliation of controlled medications, leading to loss of medications and increased risk of drug diversion.

The facility was found deficient in multiple areas including failure to maintain and document advance directives, medication administration errors, improper medication storage and labeling, failure to conduct timely laboratory tests, inadequate infection control practices, unsafe food handling and sanitation, and delayed reporting of a COVID-19 outbreak.

The investigation was complaint-related, focusing on infection control and outbreak reporting. The deficiency was substantiated with findings of failure to assess and label IV site and delayed COVID-19 outbreak reporting.

The facility failed to ensure proper infection control measures for Resident 85's intravenous site, including failure to assess, label, and change the IV dressing. Additionally, the facility did not report a COVID-19 outbreak to the California Department of Public Health in a timely manner, delaying outbreak management.

The investigation found that Resident R1 was not given their medication from 12/28/2023 around 1 PM to 12/29/2023 around 2 PM despite thirteen attempts by staff to contact R1. The facility failed to ensure R1 was assisted with medication during this time, resulting in one deficiency cited under Title 22, Division 6 of the California Code of Regulations.

The investigation found that Resident R1 was not given their medication from 12/28/2023 around 1 PM to 12/29/2023 around 2 PM despite thirteen attempts by staff to contact the resident. The facility failed to ensure medication assistance was provided, resulting in one deficiency cited under Title 22, Division 6 of the California Code of Regulations.

The investigation was triggered by a complaint related to Resident A's fractures sustained during transfers using the Hoyer lift. The complaint was substantiated as the facility failed to reassess Resident A's transfer safety and implement alternative interventions after the initial fracture.

The facility failed to ensure appropriate interventions were developed and implemented to address Resident A's high risk for fractures due to osteoporosis and history of fracture. Resident A sustained a second fracture during transfer using the Hoyer lift, and no reassessment or alternative transfer methods were documented after the first fracture.

The investigation was triggered by a complaint intake and a facility reported incident concerning the lack of a care plan for hip precautions. The complaint was substantiated by findings.

The facility failed to develop and implement a complete care plan including hip precautions for one resident after right hip arthroplasty. This failure posed potential harm by risking complications such as dislocation or fracture.

The investigation was triggered by a complaint regarding a resident-to-resident altercation involving Resident 1, who allegedly kicked another resident. The complaint was substantiated by observations, interviews, and record reviews.

The facility failed to ensure adequate supervision to prevent an altercation between residents by not providing one-on-one monitoring for Resident 1. This failure had the potential to result in further incidents involving Resident 1.

The complaint alleging that Resident’s restroom does not accommodate wheelchair access was substantiated based on interviews, observations, and document review. The facility did not provide a bedroom with adequate bathroom access for Resident R1, posing a potential health, safety, or personal rights risk.

The investigation substantiated the complaint that Resident R1 did not have access to their bathroom due to the size of the bathroom door, requiring R1 to use a bathroom outside their bedroom. The facility failed to consider R1's basic bathroom needs when moving them to different bedrooms and provided a portable commode that did not fully accommodate R1's needs. One deficiency was cited related to insufficient room to accommodate persons served in comfort and safety.

The complaint was substantiated based on evidence gathered during the investigation. The allegation that the resident's restroom does not accommodate wheelchair access was found valid.

The investigation substantiated the complaint that Resident R1's bedroom bathroom door was too small to allow access, preventing R1 from using the bathroom in their bedroom. The facility failed to provide a bedroom with adequate bathroom access, instead providing a portable commode outside the bathroom door, which did not meet R1's basic bathroom needs. One deficiency was cited related to insufficient accommodations for the resident's bathroom needs.

The complaint investigation was substantiated. The allegation involved sexual abuse witnessed by a Restorative Nursing Assistant who failed to report the incident immediately, causing a delay in investigation and protection.

The facility failed to timely report an allegation of sexual abuse towards a resident to the California Department of Public Health within the required two-hour timeframe. This delay resulted in postponed protection and investigation of the alleged abuse.

The complaint investigation focused on quality of care issues related to pressure ulcer prevention and wound documentation for Residents 1 and 2. The findings were substantiated with evidence of inadequate care and poor documentation.

The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for two residents, resulting in pressure injuries and moisture associated skin damage. Additionally, the facility failed to maintain accurate and clear medical records for wounds and skin conditions for two residents, increasing the risk of care confusion.

The visit was complaint-related, investigating complaint control #56-AS-20220809145821. The deficiency was substantiated as the cleaning supplies were accessible to residents, posing immediate health and safety risks.

The inspection found that cleaning supplies were accessible to residents in care due to an unlocked shower room and an unlocked cabinet, posing an immediate health and safety risk.

The complaint investigation was related to complaint control #56-AS-20220809145821. The deficiency was substantiated as the licensee did not comply with CCR 80087(g) by not securing cleaning supplies, posing immediate health, safety, and personal rights risks to residents.

The inspection found that cleaning supplies were accessible to residents in care because the shower room was not locked and cleaning supplies were stored on the floor and in an unlocked cabinet, posing immediate health and safety risks.

The complaint was substantiated based on interviews and observations. The air conditioning was found to be functioning but set too cold, causing discomfort to some residents.

The investigation found that the air conditioner was working but some residents felt it was set too low and too cold, requesting extra blankets or portable fans. Multiple thermostats were observed set between 73 and 76 degrees Fahrenheit, which is below the required comfortable temperature range. The allegation was substantiated.

The complaint alleging inadequate room temperatures due to air conditioning was substantiated based on interviews and observations.

The investigation found that the air conditioning was working but set too low, causing some residents to feel cold and request extra blankets or portable fans. Multiple thermostats were observed set between 73 and 76 degrees Fahrenheit, which is below the required comfortable temperature range.

The facility failed to provide appropriate treatment and care for residents with diabetes, ensure adequate nutritional care for a resident with poor food intake, and maintain safe and sanitary food preparation and storage practices in the kitchen.