Villa Coronado D/P SNF

In the surveyor’s words

From the most serious findings on record at Villa Coronado D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF732Jul 30, 2026

  Based on interview and record review, the facility failed to post nursing staffing information which reflected the actual working hours of the staff responsible for resident care.As a result, the facility's staffing information reflecting actual hours worked was not posted where the public could view it.Findings:On 7/30/26 at 2:03 P.M., an observation and interview was conducted with the Manager of Staffing and Clinical Support Services (MSCS). The MSCS stated she was responsible for the nursing staffing schedule and posting. The facility's staffing form titled, (Facility's name) Long Term Care Unit Daily Nurse Shift Staffing was posted by the nurses' station for 7/30/26. The posting was reviewed with the MSCS. […]

• No harm, potential for more than minimal, patternF812Jul 30, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food items were not properly sealed, labeled, and dated, including an open bag of grits, and an open bag of raisins, 2. Food items were not discarded when spoiled or damaged,3. The Kitchen staff (KS) did not consistently document the sanitizing log for the sinks and surface, and, 4. The [NAME] (CK) 1 did not perform hand hygiene consistently during food preparation. […]

• No harm, potential for more than minimal, patternF842Jul 30, 2026

  Based on observation, interview, and record review the facility failed to ensure residents' medical records had complete, accurate, readily accessible, and systemically organized documentation for five of 23 residents (Resident 8, 20, 28, 40, 104) when:Resident 28 and Resident 40 had incomplete and inaccurate tube feeding (liquid food delivered through a tube that was surgically placed in the stomach) intake documentation.Resident 104's care plan related to shingles (contagious rash) and contact precautions (infection prevention measures to prevent the spread of disease) was not readily accessible.Resident 8's daily wound inspection was not documented consistently after care was provided.Resident 20's psychotropic behavior monitoring was inaccurate. […]

• No harm, potential for more than minimal, patternF880Jul 30, 2026

  Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented for three of 33 sampled residents (Resident 40,113 and 101) when:1.A tube feeding pump was observed with yellowish/ brown stained while tube feeding was administered to the resident (40). 2. Certified nursing assistant (CNA) 25 did not follow the enhanced barrier precautions (EBP, an infection control strategy in long-term care facilities to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that resist common medicines and antibiotics resulting in harder to cure illnesses]) for Resident 113 during patient care.3. Licensed nurse (LN) 22 did not adhere to the EBP's hand hygiene and gloving during Resident 101's medication administration. […]

• No harm, potential for more than minimal, patternF812May 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to facility policy and standards of practice when: 1. Kitchen Staff (KS) 1 did not perform handwashing upon entering the kitchen. 2. Kitchen Staff (KS) 2 did not clean and sanitize the thermometer probe appropriately. 3. Food items were not stored appropriately when: a. Dry storage food items were not labeled and dated. b. Canned items in the dry storage were dented and not removed from the food storage. c. Outdated/expired food items in the storage room were not discarded on or before the expiration date. […]