Coronado Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF600Mar 26, 2024

  Based on clinical record review and review of facility documentation, policy and procedure, the facility failed to protect the residents' rights (#49, #216 and #175) to be free from abuse by another resident (#161 and #216) and by a visitor. The deficient practice could result in further resident abuse. Findings include: Regarding resident #49 and resident #161 -Resident #49 (alleged victim) was admitted to facility on June 16, 2019 with diagnoses of history of psychotic disturbance, mood disturbance, anxiety, anoxic brain damage, adult failure to thrive and depression. […]

• Actual harm, isolatedF757Mar 9, 2023

  Based on record clinical review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure one resident (#170) was free from unnecessary medication. The deficient practice could result in resident developing complications such as overdose. Findings include: Resident #170 was admitted on [DATE] with diagnoses that included cervical disc degeneration and hypertension. The inventory of personal items record was dated February 17, 2023 and included one hospital gown and one pair of hospital socks. There were no other items written in the list. The list was signed by two staff and the date on the list was incomplete. […]

• Actual harm, isolatedF600Jan 13, 2021

  Based on closed clinical review, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure one resident (#1) was free from neglect by failing to provide supervision and care needed to address his mental and psychosocial needs, which resulted in harm and ultimately death. Past non-compliance was identified and cited. The deficient practice could lead to residents not being provided with services necessary to meet their mental and psychosocial needs. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PASSR (Pre-Admission Screening and Resident Review) Level 1 screening dated [DATE] included the resident had a serious mental illness [DIAGNOSES REDACTED]. […]

• Actual harm, isolatedF742Jan 13, 2021

  Based on clinical review, facility documentation, staff interviews, policy and procedures, the facility failed to ensure one resident (#1) with a known suicidal ideation was provided with the treatment and services to attain his highest practicable mental and psychosocial well-being. Past non-compliance was identified and cited. The deficient practice resulted in self-harm and ultimately death of the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PASSR (Pre-Admission Screening and Resident Review) Level 1 screening dated [DATE] included the resident had a serious mental illness [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, isolatedF684Jul 17, 2026

  Based on observation, clinical record review, interviews, facility documentation, and policy, the facility failed to ensure wound care treatments were provided according to professional standards of practice and provider orders for one resident (#4) out of three sampled residents. The universe was 165. This deficient practice placed residents at risk for infection. Findings include:Resident #4 was admitted on [DATE], with diagnoses including third-degree burns of the left forearm and buttock, muscle weakness, and dysphagia.A Skin Check Assessment form dated July 9, 2026, revealed that skin issues were evaluated and locations were identified as follows:Left gluteus: Pressure ulcer measuring 3.4 cm (centimeters) length x 3.5 cm width x 0.1 cm depth. […]