Corona Post Acute Center

In the surveyor’s words

From the most serious findings on record at Corona Post Acute Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards was provided for one of three sampled residents (Resident 1) when Resident 1 was served a hot beverage by a Certified Nursing Assistant (CNA 1) without checking the safe serving temperature on April 10. 2025. This failure resulted in the hot beverage spilling on Resident 1 causing burn injuries, second degree burn [partial thickness burn - affects both the outer layer and part of the underlying layer of the skin] to third degree burn [most severe type of burn that damages all layers of the skin] on her right breast and shoulder that required medical intervention. Findings: On May 7, 2025, Resident 1's admission record was reviewed. […]

• Actual harm, isolatedF660May 23, 2024

  Based on interviews and record reviews, the facility failed for one of three sampled residents (Resident A), to ensure Resident A's discharge plan to an assisted living facility (provides support with daily activities but does not offer extensive medical care) was re-evaluated and modified when the resident developed a Stage 4 pressure injury (bed sore with severe tissue damage with exposed bone, tendon [tissue that connects the muscle to the bone], and muscle). This failure resulted in Resident A being transferred to a lower level of care facility (designed for residents who did not require specialized medical attention) leading to the worsening of the Stage 4 pressure ulcer and requiring acute hospitalization . […]

• No harm, potential for more than minimal, widespreadF812May 17, 2022

  Based on observation, interview, and record review, the facility failed to ensure dietary staff was able to safely and effectively carry out the functions of food and nutrition services when: 1. The dietary staff did not perform testing of sanitizing solution properly; 2. The dietary staff did not use the designated scoop for the ice; and 3. The dietary staff entered the kitchen without performing handwashing. Findings: 1. On May 12, 2022, at 3:05 p.m., the Dietary Staff (DS) was observed testing sanitizing solution for dishwashing machine using the chlorine test strip. The DS was observed dipping the test strip for approximately 3 seconds, removed the test strip and compared with the color chart. […]

• No harm, potential for more than minimal, patternF578Apr 10, 2026

  Based on interview and record review, the facility failed to ensure, 13 of 15 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD and have an AD available for review in the medical record.These failures had the potential to result in the ADs for Residents (17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159) not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1.On April 10, 2026, at 3 p.m. […]

• No harm, potential for more than minimal, patternF605Apr 10, 2026

  Based on interview and record review, the facility failed to ensure five of five sampled residents (Residents 2, 16, 45, 119, 159) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 16 was administered quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) for diagnosis of schizophrenia without documentation to support the diagnosis per The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, globally recognized standard classification system for diagnosing mental disorders by the American Psychiatric Association); and manufacturer specified monitoring were not done during use of quetiapine;2. […]