Coronado at Stone Oak

In the surveyor’s words

From the most serious findings on record at Coronado at Stone Oak, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 11, 2021

  Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the residents' clinical condition and the residents' choice for 1 of 4 Resident (Resident #1) reviewed for quality of care, in that: RN A and LVN B failed to properly assess and administer life-saving measures including CPR to Resident #1 who was full code status when he was found without respirations and unresponsive. RN A and LVN B performed outside of their nursing scope of practice by pronouncing death to Resident #1 without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 11:47 a.m. […]

• Actual harm, isolatedF580Jan 7, 2021

  Based on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 4 residents (Residents #1) reviewed for a notification of a change of condition, in that; RN B did not notify Resident #1's physician of a critically high [MEDICATION NAME] trough level resulting in continued administration of medication. Resident #1 had increased [MEDICATION NAME] levels and was admitted to the hospital. This failure to consult with the physician regarding a change of condition could result in delay of medical treatment, [MEDICAL CONDITION], and hospitalization . The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. […]

• Actual harm, isolatedF760Jan 7, 2021

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident # 1) reviewed for significant medication errors, in that; The facility failed to monitor Resident #1's [MEDICATION NAME] trough levels as ordered by a physician prior to administering IV (intravenous) [MEDICATION NAME] which resulted in increased blood levels of the medication, hospitlization, [MEDICAL CONDITION]. This failure placed residents at risk for not receiving therapeutic dosages and placed them at risk for a decline in health. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, patternF812Jul 17, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service sanitation and safety, in that:During the initial tour on 7/14/26:---The facility failed to ensure 3 portion plates and 4 baking pans were not upside down with food contact surfaces exposed. ---The facility failed to ensure an open box of Cream of Wheat was not on top of a warm oven. ---The facility failed to ensure 2 containers of soup base were not opened and not refrigerated as recommended on the labels. ---The facility failed to ensure there was not an unsecured overhead cover in the pantry. […]

• No harm, potential for more than minimal, patternF842Jan 28, 2026

  Based on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for medical records. 1. The facility failed to ensure Resident #1's ADL-Bathing record recorded a bath or refusal for 1/19/2026, as noted on the electronic medical record. 2. The facility failed to ensure Resident #2's ADL-Bathing record recorded a bath or refusal for 1/2/2026 and 1/19/2026, as noted on the electronic medical record. 3. The facility failed to ensure Resident #3's ADL-Bathing record recorded a bath or refusal for 1/26/2026, as noted on the electronic medical record. 4. […]