Coronado Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 16, 2022

  Based on record review and interview the following was identified: 1. R#1 had an indwelling Foley Catheter (the Foley is a hollow, flexible tube that is inserted into the bladder through the urethra) with drainage bag that needed to be emptied every shift. 2. Beginning [DATE], nurse aides began documenting that R #1 had dark brown urine when the drainage bag was emptied. 3. Interviews conducted with licensed and registered nurses indicated nurse aides did not communicate to them when R#1's urine was dark brown. 4. Visit note reports from Hospice dated [DATE], [DATE], and [DATE] indicated R #1's urine had a strong, foul odor. The notes indicated dark brown urine draining with thick, mucousy sediment (gritty particles or [MEDICATION(S)] in the urine) in the tubing. 5. […]

• No harm, potential for more than minimal, widespreadF812Jun 13, 2025

  Based on observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items stored in facility's freezer were labeled and dated. This deficient practice is likely to affect 76 residents listed on the resident census list provided by the Administrator on 06/09/25 and could likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 06/09/25 at 11:03 am during observation of the facility's walk in freezer the following items were found open and undated: 1. Two bags of what appeared to be hash browns. 2. Two bags of what appeared to be French fries. B. […]

• No harm, potential for more than minimal, widespreadF728May 17, 2024

  Based on record review and interview, the facility failed to provide documentation confirming one Nurse Aide (NA), employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 68 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: A. Record review of NA #1's personnel record revealed the following: - The NA's hire date was 12/01/23; - The record did not contain a Certified Nursing Assistant (CNA) License. […]

• No harm, potential for more than minimal, widespreadF812May 17, 2024

  Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the dry storage area were stored properly. 2. Ensure all food items in the walk-in refrigerator were labeled and dated. 3. Ensure all food items in the freezer were sealed appropriately. This deficient practice is likely to affect all 75 residents identified on the resident census list provided by the Director of Nursing on 05/13/2024. These deficient practices are likely to expose residents to food borne illnesses. The findings are: Dry Storage Area: A. […]

• No harm, potential for more than minimal, widespreadF656May 16, 2023

  Based on record review, observation, and interview the facility failed to 1) Develop a comprehensive care plan and 2) Implement a comprehensive care plan for 4 (R #2, 30, 31 and 41) of 4 (R #2, 30, 31 and 41) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being. the findings are: Findings for R #2 A. Record review of facility face sheet for R #2 admitted on [DATE] revealed admission diagnoses which included: Heart Disease (conditions that affect the heart's function and blood flow), Kidney Failure (kidneys no longer function well on their own), Reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), Obesity (overweight), Hernia (organ or tissue… […]