Inspection Reports for Coronado Ridge Skilled Nursing and Rehabilitation Center
2855 W Horizon Ridge Pkwy, Henderson, NV 89052, NV, 89052
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% better than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide documented evidence of actions taken and follow-up after notification of a resident testing positive for Legionella.
Complaint Details
Complaint 2603300. The investigation found the facility did not document or follow up appropriately after notification from the hospital on 08/06/2025 that a resident tested positive for Legionella. The Infection Preventionist Nurse did not ask sufficient questions, did not document the call, and did not initiate appropriate infection control measures or reporting. The facility did not test the water system after the positive case and did not conduct resident tracking or surveillance as required.
Findings
The facility failed to adequately respond to a reported positive Legionella case in a discharged resident, including lack of documentation, failure to investigate or test the water system after notification, and failure to report the infection to the Health District as required.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program related to Legionella surveillance and response.
Report Facts
Residents sampled: 9
Residents affected: 1
Date of discharge: Aug 2, 2025
Date of water system test: 202502
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist Nurse | Infection Preventionist Nurse | Named in relation to failure to document and follow up on Legionella positive case |
| Director of Nursing | Director of Nursing | Informed by IP Nurse about Legionella positive case |
| Assistant Director of Nursing | Assistant Director of Nursing | Informed by IP Nurse about Legionella positive case |
| Maintenance Director | Maintenance Director | Informed about Legionella positive case and water system testing |
| Administrator | Administrator | Not aware of hospital notification call and declined further water testing |
| Clinical Resource | Clinical Resource | Provided expert opinion on appropriate infection control actions |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 15, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding the facility's failure to ensure proper care planning, safe administration of IV fluids, respiratory care, pain management, and proper documentation of life-sustaining treatment orders for residents.
Complaint Details
The complaint investigation focused on multiple residents (Residents 3, 7, 154, 155, and 157) regarding failures in care planning, IV fluid administration, oxygen therapy, pain management, and documentation of DNR orders. The deficiencies had the potential to place residents at risk for harm including infection, respiratory failure, unmanaged pain, and receiving care inconsistent with their resuscitation preferences.
Findings
The facility was found deficient in multiple areas including failure to initiate baseline care plans for residents admitted with peripheral IV access, failure to obtain clarification orders and follow physician orders for IV line maintenance and removal, failure to ensure oxygen therapy was properly ordered and administered, inadequate pain management including lack of physician orders and monitoring, and failure to properly document and witness verbal consent for do not resuscitate (DNR) orders on POLST forms.
Deficiencies (5)
Failed to ensure a baseline care plan was initiated and completed for a resident admitted with peripheral IV access.
Failed to provide safe, appropriate administration of IV fluids including obtaining clarification orders and following physician orders for IV site rotation and removal.
Failed to ensure a resident requiring oxygen therapy was not connected to an empty oxygen tank and lacked a physician's order for oxygen.
Failed to provide safe and appropriate pain management including obtaining physician orders for moderate to severe pain, routine pain monitoring, and offering pharmacological and non-pharmacological interventions.
Failed to ensure a Physician Order for Life-Sustaining Treatment (POLST) form was witnessed and signed by two staff members to validate verbal consent for DNR status.
Report Facts
Sampled residents: 24
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed deficiencies related to baseline care plan, IV line maintenance, and POLST documentation |
| Licensed Practical Nurse 1 | LPN | Reported on IV site rotation and pain management issues for Resident 155 and Resident 154 |
| Clinical Resource Nurse | Clinical Resource Nurse | Confirmed facility protocols and deficiencies related to IV line rotation and pain assessment |
| Infection Preventionist | Infection Preventionist (IP) | Removed peripheral IV line and acknowledged documentation deficiencies |
| Registered Nurse | RN | Verified oxygen tank was empty and no active order for oxygen for Resident 157 |
| Licensed Practical Nurse 2 | LPN | Reported removal of peripheral IV line for Resident 155 |
| Licensed Practical Nurse 3 | LPN | Administered pain medication and reported pain management issues for Resident 154 |
| Nurse Practitioner | Nurse Practitioner (NP) | Discussed pain medication orders and management for Resident 154 |
| Consultant Pharmacist | Consultant Pharmacist | Reviewed medication dispensing issues related to pain management for Resident 154 |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The inspection was conducted as a result of a Complaint and Facility-Reported Incidents (FRI) investigation in the facility on 04/16/2025, focusing on three complaints and one facility-reported incident.
Complaint Details
There were three complaints and one facility-reported incident investigated. Complaints #NV00073445 and #NV00073171 were substantiated with deficiencies. Complaint #NV00073391 was substantiated without deficient practice. The facility-reported incident #NV00073821 was unsubstantiated with no regulatory deficiencies identified.
Findings
Three complaints were substantiated, two with deficiencies and one without deficient practice; one facility-reported incident was unsubstantiated with no regulatory deficiencies identified. A key deficiency was identified in pain management, where the facility failed to ensure proper administration and timely assessment of pain medication for sampled residents.
Deficiencies (1)
Failure to ensure resident's pain medication was administered as ordered and pain was timely assessed, resulting in unmanaged pain and decreased quality of life for affected residents.
Report Facts
Census: 105
Sample size: 5
Complaints investigated: 3
Facility-reported incidents investigated: 1
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pain management protocols and medication administration for residents, specifically focusing on pain medication administration and pain assessment practices.
Findings
The facility failed to administer pain medication as ordered for one resident and did not timely assess pain for another resident, resulting in potential unmanaged pain and decreased quality of life. Documentation and communication issues regarding medication orders and pain assessments were identified.
Deficiencies (2)
Failure to ensure the resident's pain medication was administered as ordered and appropriately managed for 1 of 5 sampled residents.
Pain was not timely assessed for 1 of 5 sampled residents upon admission.
Report Facts
Hydromorphone dosage: 4
Hydromorphone dosage: 6
Pain level: 10
Pain assessment date: Feb 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed medication order issues and pain assessment deficiencies |
| Nurse Supervisor | Nurse Supervisor | Confirmed new medication order was received but not administered and pain assessment was not completed |
| Registered Nurse | Registered Nurse | Uncertain why increased dosage was not administered and explained pain assessment should have been done upon admission |
| Occupational Therapist | Occupational Therapist | Observed resident in severe pain and confirmed ongoing pain issues |
| Physical Therapist | Physical Therapist | Verified resident's pain level and importance of medication for therapy participation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 2, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to obtain informed consent prior to administration of psychotropic medications for Resident 1 and failure to develop and implement a complete care plan after an allegation of physical abuse for Resident 3.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to obtain informed consent for psychotropic medications for Resident 1 and failure to develop a care plan after an abuse allegation for Resident 3. The facility disputed the citation regarding the care plan for Resident 3.
Findings
The facility failed to ensure informed consent was obtained before administering psychotropic medications to Resident 1, violating its antipsychotic use policy. Additionally, the facility failed to initiate a care plan addressing abuse allegations and related interventions for Resident 3, placing the resident at risk for inappropriate care and supervision.
Deficiencies (2)
Failure to ensure informed consent was obtained prior to administration of psychotropic medications for Resident 1.
Failure to develop and implement a complete care plan after a resident alleged physical abuse for Resident 3.
Report Facts
Psychotropic medication orders without informed consent: 3
Residents sampled: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development (DSD) | Explained informed consent process for psychotropic medications. | |
| Registered Nurse (RN) | Provided information about informed consent forms and medication administration for Resident 1. | |
| Assistant Director of Nursing (ADON) | Described training and process for informed consent completion. | |
| Director of Nursing (DON) | Reviewed medical records, confirmed lack of consent forms, and acknowledged care plan deficiencies. | |
| Consultant Pharmacist | Explained regulatory requirements for informed consent on psychotropic medications. | |
| Licensed Practical Nurse (LPN) | Unaware of Resident 3's Cares in Pairs care plan requirement. | |
| Certified Nursing Assistant (CNA) | Unaware of Resident 3's Cares in Pairs care plan requirement. |
Inspection Report
Routine
Deficiencies: 5
Date: Aug 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, and facility safety at Coronado Ridge Skilled Nursing & Rehabilitation Center.
Findings
The facility failed to develop baseline care plans for medical devices for two residents, did not ensure documentation of ordered therapeutic device applications for one resident, failed to monitor psychoactive medication side effects for one resident, and left medications unsecured on one medication cart and at one resident's bedside. These deficiencies posed risks for resident discomfort, skin integrity issues, medication errors, and compromised safety.
Deficiencies (5)
Failure to develop baseline care plans for a soft collar device, ACE wrap dressing, and CAM boot device for 2 of 22 sampled residents.
Failure to ensure documentation of application of ordered TED stockings for 1 of 22 sampled residents.
Failure to obtain, transcribe, and carry out care and management orders for soft collar device, ACE wrap, and boot device and delay in scheduling post-operative appointment for 2 of 22 sampled residents.
Failure to document psychoactive medication side effects monitoring for 1 of 22 sampled residents.
Failure to ensure medications were secured on 1 of 6 medication carts and failure to remove an unsecured bottle of hydrogen peroxide from a resident's bedside.
Report Facts
Residents sampled: 22
Medication carts: 6
Unsigned MAR dates: 8
Post-operative appointment delay: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Reviewed medical records and confirmed missing baseline care plans for Residents 244 and 250 | |
| Director of Nursing (DON) | Acknowledged missing care plans and delays in post-operative appointments and care | |
| Assistant Director of Nursing (ADON) | Confirmed unsigned MAR entries and lack of justification for missing documentation | |
| Treatment Registered Nurse (RN) | Provided information on wound care and delays in follow-up appointments for Resident 250 | |
| LPN Case Manager #1 | Confirmed lack of knowledge of Resident 250's surgeon and missing follow-up appointment | |
| LPN Case Manager #2 | Confirmed missing follow-up appointment and importance of surgeon input for Resident 250 | |
| Unit Manager | Observed medication cart left unlocked and reminded nurse to keep it locked | |
| Registered Nurse | Explained behavior monitoring for psychotropic medication side effects |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a standard annual survey of Coronado Ridge Skilled Nursing & Rehabilitation Center to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in several areas including failure to obtain physician orders for treatments such as compression stockings, improper Foley catheter care and documentation, failure to follow pain medication order parameters, inadequate sanitizing solution concentration in the kitchen, and deficiencies in the arbitration agreement provisions.
Deficiencies (5)
Failure 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.
Failure to ensure the correct size of an indwelling urinary catheter (Foley) was followed as ordered or clarified, and Foley care and management were transcribed and implemented for 2 of 32 sampled residents.
Failure to ensure the ordered parameters for pain medication were followed as ordered for 1 of 32 sampled residents.
Failure to maintain a level of quaternary ammonia between 200 and 400 parts per million in the 3-compartment sink and failure to prevent water splashing from the floor sink drain.
Failure to provide a neutral and fair arbitration process including selection of a neutral arbitrator and venue convenient to both parties.
Report Facts
Residents sampled: 32
Foley catheter size order: 18
Foley catheter size observed: 16
Quaternary ammonia concentration: 0
Quaternary ammonia recommended concentration range: 200-400
Pain level order parameter: 6-10
Pain level recorded when opioid administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Confirmed resident had compression stockings and described usage | |
| Licensed Practical Nurse (LPN) | Reported no physician order for compression stockings and Foley catheter care; confirmed pain medication order deviations | |
| Nurse Practitioner (NP) | Indicated need for physician orders for compression stockings and Foley catheter; explained pain medication order parameters | |
| Registered Nurse Manager (RNM) | Explained Foley catheter utilization process and documentation requirements | |
| Director of Nursing (DON) | Confirmed lack of Foley catheter orders and care management documentation in MAR | |
| Director of Staff Development (DSD) | Confirmed deficiencies in Foley catheter care and pain medication order adherence; described Foley catheter training | |
| Food Services Manager | Confirmed low quaternary ammonia concentration and water splashing issues in kitchen sink area | |
| Licensed Practical Nurse (LPN) | Confirmed pain medication order deviations and explained Foley catheter care | |
| Assistant Director of Nursing (ADON) | Reviewed medical records and confirmed lack of documented Foley catheter care | |
| Director of Admissions | Confirmed arbitration agreement lacked provisions for neutral arbitrator and convenient venue |
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