Inspection Reports for Coronado Nursing and Rehabilitation Center

The inspection was conducted to evaluate compliance with medication storage regulations, specifically ensuring drugs and biologicals are labeled and stored in locked compartments according to professional standards.

The facility failed to store drugs and biologicals in locked compartments during medication storage inspection, with medication cart #1 found unlocked and accessible to residents and staff, posing risks of medication diversion, overdose, or allergic reactions.

The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to the development and implementation of comprehensive, person-centered care plans for residents.

The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 6 of 6 residents reviewed. Additionally, the facility did not ensure that nurse aides with responsibility for the residents were invited to or attended care plan conferences, which could impact the quality of care provided.

The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication consent, environmental safety, medication storage, food safety, and infection control at Coronado Nursing Center.

The facility was found deficient in multiple areas including failure to obtain proper consent for antipsychotic medications for residents, inadequate care planning with unmeasurable objectives, unsafe environmental conditions such as a broken toilet, improper medication storage in resident refrigerators, food safety violations including improper thawing and handling, failure to maintain temperature logs for resident refrigerators, and failure to use required PPE during Foley catheter care.

The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents or their representatives were fully informed and had signed consent for antipsychotic medication treatment prior to administration.

The facility failed to obtain signed consent from residents or their representatives for antipsychotic medication Seroquel for 2 of 23 residents reviewed (Resident #29 and Resident #44). Verbal consents were obtained in some cases, but written consent was not documented as required. This failure placed residents at risk of not being informed about their health status and treatment options.

The complaint investigation found that the facility did not have signed consents for antipsychotic medication for Residents #29 and #44. Verbal consent was obtained for Resident #29 but was not considered compliant with regulations. The Director of Nursing and other staff confirmed the lack of proper consent documentation and identified barriers such as family non-responsiveness. The facility policy requires written consent prior to administration of psychotropic medications.

The inspection was conducted due to complaints regarding the presence of cockroaches in residents' bathrooms and allegations of abuse involving Resident #3.

The facility failed to maintain a safe, clean, and homelike environment by not adequately controlling cockroach infestations in Resident #3 and Resident #8's bathrooms and common areas. Additionally, the facility failed to timely report and properly investigate an allegation of abuse involving Resident #3 by CNA B, and did not prevent further potential abuse by allowing the alleged staff member to remain on duty.

The complaint involved Resident #3 and Resident #8 regarding cockroach infestations in their bathrooms and common areas. Additionally, a family member of Resident #3 alleged abuse by CNA B, which was not reported timely or properly investigated by the facility.

The inspection was conducted due to concerns about infection prevention and control practices related to COVID-19 exposure and transmission among residents.

The facility failed to implement an effective infection prevention and control program, resulting in COVID-19 positive residents being cohorted with negative residents, improper use of PPE by staff, and failure to quarantine COVID-19 positive residents, leading to exposure of multiple residents. An Immediate Jeopardy was identified but removed after corrective actions.

The investigation was complaint-driven due to allegations of inadequate infection control leading to COVID-19 exposure among residents. Immediate Jeopardy was identified on 10/11/2024 and removed on 10/13/2024 after corrective actions.

The inspection was conducted due to concerns about the facility's failure to establish and maintain an infection prevention and control program, specifically related to COVID-19 isolation and PPE practices.

The facility failed to isolate COVID-19 positive residents from negative residents, failed to ensure staff changed PPE between positive and negative residents, and allowed COVID-positive residents to leave quarantine, exposing others. Immediate Jeopardy was identified but removed after corrective actions were implemented.

The visit was complaint-related due to allegations of inadequate infection control practices leading to COVID-19 exposure among residents. Immediate Jeopardy was identified on 10/11/2024 and removed on 10/13/2024 after corrective actions.

The inspection was conducted due to a complaint investigation regarding failure to timely report suspected abuse, neglect, or theft and failure to provide proper discharge procedures for residents.

The facility failed to timely report allegations of abuse and neglect related to an elopement incident involving Resident #1 and failed to provide proper discharge documentation and procedures for Resident #2. Additionally, the facility failed to develop a comprehensive person-centered care plan addressing supervision needs for Resident #1 and failed to provide adequate supervision to prevent Resident #1's elopement, resulting in an Immediate Jeopardy that was later removed.

The complaint investigation was triggered by an elopement incident involving Resident #1 on 04/18/2024, where the facility failed to report the incident timely to the State Survey Agency. The investigation also included concerns about improper discharge procedures for Resident #2 and inadequate supervision leading to Resident #1's elopement.

The inspection was conducted due to complaints regarding failure to provide necessary care and assistance to residents, specifically related to showering and transfers, and concerns about insufficient nursing staff to meet resident needs.

The facility failed to provide showers to Resident #10 as requested and failed to assist Resident #12 with transfers from bed to chair as requested. Additionally, the facility was found to be understaffed, with insufficient nursing staff hours to meet resident care needs, potentially impacting resident safety and well-being.

The complaint investigation found substantiated issues including Resident #10 not receiving showers for three weeks and Resident #12 not being assisted with transfers as requested. Residents and administration acknowledged staffing shortages contributing to these issues.

The inspection was conducted to evaluate compliance with regulatory requirements including resident fund security, resident assessments, care planning, RN coverage, food service, infection control, and staffing.

The facility failed to maintain adequate surety bond coverage for resident funds, accurately assess residents, develop comprehensive care plans with measurable objectives, ensure attendance of attending physicians and nurse aides at care plan conferences, provide 8 hours of RN coverage daily, serve palatable and properly prepared food, label and date opened food items, employ a full-time social worker, and maintain proper infection control during catheter care.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, safety, staffing, infection control, and food service.

The facility was found deficient in multiple areas including inadequate surety bond coverage for residents' funds, inaccurate resident assessments, incomplete care plans lacking measurable objectives, failure to include attending physicians and nurse aides in care plan conferences, improper use and assessment of bed rails, insufficient RN coverage, unpalatable food service, improper food labeling, lack of full-time social worker, and failure to maintain infection control protocols during catheter care.

The inspection was conducted as a follow-up to investigate the security and accountability of controlled narcotic medications after a discrepancy was discovered involving missing hydrocodone-acetaminophen tablets.

The facility failed to maintain an accurate system of records for controlled drugs and failed to secure hydrocodone-acetaminophen 10-325mg, resulting in 180 tablets missing from the medication cart. The medication was discontinued after discovery, and the facility was unable to identify when or who was involved in the loss. No evidence of destruction or proper accountability was found.

The document is an annual inspection survey conducted at Coronado Nursing Center to assess compliance with health regulations.

No health deficiencies were found during the inspection.

The inspection was conducted to evaluate compliance with regulatory requirements including abuse prevention, PASRR coordination, activity provision, nurse staffing posting, medication labeling, and food service safety at Coronado Nursing Center.

The facility failed to implement abuse prevention policies by not completing reference checks for six employees prior to hire. It also failed to coordinate PASRR assessments for residents with new mental health diagnoses, provide adequate individual activities for bed-bound residents, post complete nurse staffing hours daily, ensure medication labeling and disposal of expired drugs, and maintain food safety by preventing personal cell phones in food prep areas.

The inspection was conducted due to a complaint investigation regarding the facility's failure to establish a system of records for receipt and disposition of controlled drugs, specifically concerning medication reconciliation for Resident #1.

The facility failed to have safeguards and systems in place to control, account for, and periodically reconcile controlled medications, resulting in missing Xanax medication and potential risk of drug diversion or accidental exposure. Interviews revealed lack of training and unclear responsibilities among staff, including the Director of Nursing and Assistant Director of Nursing, contributing to the medication discrepancy.

The investigation was complaint-related, focusing on missing controlled medications (Xanax) for Resident #1. The complaint was substantiated by findings of missing medication and inadequate medication reconciliation processes.

The document is an annual inspection report for Coronado Nursing Center conducted to assess compliance with health regulations.

No health deficiencies were found during the inspection.

The inspection was conducted following a complaint regarding Resident #1 being observed masturbating in Resident #2's room with Resident #2 present, which raised concerns about the facility's failure to develop and implement a comprehensive person-centered care plan addressing this behavior.

The facility failed to revise the individualized care plan for Resident #1 after multiple observations of inappropriate sexual behavior, including masturbating in another resident's room and in the dining area. The facility took some actions such as moving Resident #2 to another room and placing Resident #1 on observation, but did not adequately document interventions or revise the care plan accordingly. Interviews with staff and the administrator revealed differing views on the behavior and its care planning.

The complaint involved Resident #1 masturbating in Resident #2's room with Resident #2 present and later in the dining room watching inappropriate videos. Resident #2's family member reported the incident. Resident #1 denied the behavior. The facility moved Resident #2 to another room and placed Resident #1 on 15-minute observation for 24 hours. Multiple attempts to contact Resident #2's family member and agency CNA were unsuccessful.

The inspection was conducted to investigate multiple deficiencies related to resident care, safety, staffing, infection control, medication management, and regulatory compliance at Coronado Nursing Center.

The facility was found to have multiple deficiencies including failure to provide adequate resident care, insufficient staffing, failure to follow physician orders, inadequate infection control practices, failure to maintain accurate assessments and care plans, medication management issues, and environmental hazards. Immediate jeopardy was identified related to catheter care and wound management but was removed after corrective actions.