Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coronado Healthcare Center during CMS and state inspections, most recent first.
Two residents’ care plans were not updated to reflect known behaviors and treatment needs. One resident with multiple sclerosis, anxiety, bipolar disorder, and moderate cognitive impairment repeatedly called 911 for brief changes due to confusion and anxiety, but this behavior was not included in the care plan despite staff awareness and facility expectations that behaviors be care planned. Another resident with TBI, epilepsy, dementia, and mood disorders had an active order and care plan focus to wear a helmet when out of bed, supported by physician notes and therapy training, yet was repeatedly observed ambulating without the helmet, while staff were unsure of the order, could not find it on the MAR/TAR, and had not documented refusals or any discontinuation. The DON and policies confirmed that refusals and high-risk services must be documented and incorporated into the care plan, but the resident’s electronic care plan lacked the noted refusal, demonstrating a failure to maintain accurate, updated care plans.
A resident with COPD, dementia, bipolar disorder, anxiety, moderate cognitive impairment, and documented depression had a care plan calling for participation in activities, structured interventions for elopement risk, and non-pharmacological approaches to support psychotropic use, yet activity logs over a month showed participation on only two days and almost no documented attendance over two months. Observations revealed the resident alone in a hallway or in bed while other residents sat in common areas with a loud TV, no structured activities, and minimal staff interaction. The Activity Director reported very limited activities staffing, no dedicated weekend coverage, reliance on CNAs to provide undocumented activities when time allowed, and no consistent documentation of refusals or inability to participate, despite a policy requiring documentation when residents cannot participate and affirming residents’ rights to choose activities.
A resident with epilepsy and traumatic brain injury had an active physician order and care plan intervention to wear a protective helmet when out of bed, with no documented discontinuation or pattern of care refusal. Over multiple observations, the resident was repeatedly seen standing, ambulating, and participating in activities without the helmet, despite visible room signage directing helmet use. Nursing staff, including an LPN and a CNA, were unaware or uncertain about the ongoing helmet order, assumed it had been discontinued, and could not locate a corresponding treatment entry or refusal documentation on the MAR/TAR. Therapy leadership confirmed the resident had been trained to use the helmet and was discharged from therapy with the expectation of continued helmet use and staff cueing, while the DON verified the order remained active and emphasized that orders and refusals should be accurately implemented and documented, consistent with facility policies on physician orders and charting.
Surveyors found multiple food storage and sanitation issues in the dietary department, including food debris under shelving in dry storage, an ice machine with gray, wet debris on its rubber rims, and unit refrigerators with spilled liquid left on shelves. In the main kitchen refrigerator and freezer, several food items such as applesauce, sheet cakes, burger patties, ground beef, cheese, and egg rolls were observed uncovered, exposed to air, and undated. During a tray line observation, hot foods including chicken, mixed vegetables, and baked bread pudding were recorded at 115–120°F. The dietary manager reported that dishwashing staff are responsible for sweeping and mopping floors after meals, that cleaning is not done after breakfast due to workload, and that he oversees these tasks, despite a facility policy requiring food storage areas to be clean at all times.
A resident with severe cognitive impairment and a court-appointed legal guardian experienced multiple changes in medical condition, including medication adjustments and new diagnoses. Despite facility policy and staff understanding that the legal guardian should be notified, documentation showed that only the resident was informed of these changes, and there was no evidence of communication with the legal guardian during key events.
A resident with multiple pressure ulcers and diabetic foot ulcers did not receive ordered wound care treatments on several occasions. Documentation showed missed treatments without evidence of follow-up attempts, coordination for alternate times, or communication to subsequent shifts. Nursing staff and the DON confirmed that facility expectations and policies required follow-up and documentation, but these actions were not reflected in the clinical record.
A resident admitted with multiple infections did not receive IV site dressing changes as ordered by the physician. Although the MAR indicated the dressing was changed, observation revealed the original hospital dressing remained in place past the required interval. Staff confirmed the dressing had not been replaced, contrary to facility policy and physician orders.
A registered nurse failed to don a gown, as required by Enhanced Barrier Precautions (EBP), while providing central line care to a resident with wounds and a central line. Despite physician orders and facility policy specifying the use of both gown and gloves for high-contact care activities, only gloves were used during the procedure.
The facility failed to protect residents from abuse by other residents and visitors. Incidents included physical altercations between residents with cognitive impairments and a visitor hitting a resident with a purse, resulting in injuries. The facility documented these as isolated events and took immediate action to separate and assess the residents involved.
A resident with cognitive impairments and multiple medical conditions eloped from the facility. Despite being assessed as low risk for elopement, the resident set off the front door alarm and was later found walking down a nearby avenue. Staff were unable to catch up to the resident, who refused to return. The facility lacked proper documentation and did not inform the resident's public fiduciary, who had full guardianship.
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation where one resident kicked and caused a skin tear on the other's forearm. Despite the facility's abuse prevention policy, staff interviews and progress notes confirmed the incident, and the Operations Manager could not recall the event.
A resident was discharged with medications not prescribed to her, including those belonging to other residents. The discharge process failed to properly reconcile and verify medications, leading to potential harm.
Failure to Update Care Plans for Behavioral 911 Calls and Ordered Helmet Use
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect known behaviors and treatment needs for two residents. For the first resident, who had multiple sclerosis, bipolar disorder, anxiety disorder, and a cognitive communication deficit, the MDS documented moderate cognitive impairment and dependence on staff for multiple ADLs. A complaint was filed stating that this resident had called 911 to request a brief change and had a history of doing so. Staff interviews confirmed that the resident experienced anxiety and sundowning, frequently believed she had pressed the call light when she had actually pressed the bed remote, and then, in a panic, dialed 911 for assistance with brief changes. Despite this ongoing behavior, the resident’s care plan, initiated in early 2022 and revised over time, did not include the behavior of calling 911 for brief changes. The acting DON stated that residents’ behaviors are always supposed to be documented in the care plan so clinical staff know what behaviors to expect. CNAs interviewed described the resident’s pattern of anxiety, confusion, and repeated 911 calls when she believed she had not received needed incontinence care, even though staff reported that brief changes were completed frequently. However, there was no evidence in the care plan that this behavior had been identified, addressed, or incorporated into the resident’s person-centered interventions, despite the facility’s own expectation that such behaviors be care planned. For the second resident, who had epilepsy, traumatic brain injury with brain compression and herniation, alcoholic cirrhosis, thrombocytopenia, hypertension, unspecified dementia with moderate cognitive impairment, anxiety disorder, and mood disorders including depression, the care plan and orders required the resident to wear a helmet when out of bed. A care plan focus initiated in mid-2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included wearing a helmet out of bed. An active order entry and physician progress notes documented that the resident was to utilize a helmet when out of bed. There was no evidence in the care plan that the resident refused the helmet or that helmet use had been discontinued. Observations over multiple days showed the resident repeatedly out of bed, standing, walking in his room, in activities, and in the dining room without the helmet, even though a sign in the room initially stated “HELMET ON AT ALL TIMES OUT OF BED,” and the helmet was visible on the nightstand. Nursing and CNA staff interviews revealed uncertainty about why the resident needed the helmet, whether the order was still active, and whether therapy had discontinued it. One LPN stated she had not seen the resident wear the helmet and was unaware of the order, and could not locate the helmet treatment on the MAR/TAR, even though she acknowledged that such an appliance should be documented there and that refusals should be recorded and communicated. A CNA reported that the resident used to wear the helmet more frequently but did not know why he stopped or why he should be wearing it, and had never been instructed to assist with or educate about helmet use. The director of rehabilitation confirmed that therapy had assessed and trained the resident and staff on helmet use, that the resident had been discharged from therapy with the expectation to continue helmet use out of bed, and that there was no documentation that the helmet had been discontinued. The interim DON stated that the facility is expected to follow provider orders as written, that care plans must be updated quarterly and as needed, and that refusals of care should be documented and reflected in the care plan so providers can make necessary changes. When reviewing the resident’s care plan, the interim DON believed there was a note indicating the resident refused the helmet, but the care plan retrieved from the electronic health record did not contain such a note, and she was unsure about the documentation discrepancy. Facility policies on comprehensive person-centered care planning and documenting and charting required that refusals of services posing health and safety risks be identified in the care plan, including the declined care, associated risks, and the interdisciplinary team’s educational efforts, and that the medical record provide a complete account of care and treatment. For both residents, the survey findings showed that the care plans were not updated and revised to accurately reflect known behaviors and treatment orders, leading to incomplete and inconsistent documentation of their current care needs and interventions.
Failure to Provide Ongoing, Individualized Activities Program for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of a resident. The resident was admitted with COPD, unspecified dementia of moderate severity, bipolar disorder, anxiety, and was receiving scheduled antipsychotic and psychotropic medications. The comprehensive care plan identified that the resident participated in activities such as bingo and ice cream socials, and included interventions such as inviting the resident to scheduled activities, providing a monthly activities calendar, and establishing and recording prior activity involvement and interests. Additional care plan focuses included elopement risk/wandering, with interventions such as structured activities (toileting, walking inside and outside, reorientation strategies), and psychotropic medication use with non-pharmacological interventions including back rubs, redirection, calm approach, repositioning, providing a quiet environment, and taking the resident to activities. Review of the most recent quarterly MDS showed the resident had a BIMS score of 9 (moderate cognitive impairment) and a Resident Mood Interview score of 13, indicating moderate depression and that the resident sometimes felt socially isolated. The MDS also documented that the resident required maximum assistance with toileting, bathing, and transfers. Review of the social activity task log for a 30-day period showed the resident participated in activities on only two days. Paper activity participation logs for two consecutive months showed the resident had no documented attendance for one month and only one documented activity for the prior month. Activity calendars for both the secured and non-secured units listed only a limited set of group activities (bingo, coffee social, woodworking, table games, open activities) and were identical for both units, without individualized or unit-specific programming for residents on the secured unit. Multiple observations showed a lack of structured or documented activities and minimal staff engagement. The resident was observed alone in a hallway in a wheelchair with no staff nearby while other residents sat in a common area with a loud television and some staring at the wall. During a scheduled ice cream social, no activities were occurring and the resident was not present in the common area. On another occasion, several residents were in the common area while staff sat in a secluded nursing desk area conversing, with the television on but no staff interaction, structured activities, or resident socialization observed; later, the resident was found in bed with covers drawn and lights off. The Activity Director reported having only one light-duty CNA to assist on limited days, no activities staff on weekends, and reliance on CNAs to provide activities when they had time, without consistent documentation of refusals or non-applicability. CNAs confirmed there was no set time for activities on the secured unit, that they provided activities only if time allowed, and that they did not document these activities. The facility’s policy stated that residents have the right to choose activities and that reasons for inability to participate should be documented in the medical record, but such documentation was not described in the findings.
Failure to Implement and Document Physician Order for Protective Helmet Use
Penalty
Summary
The deficiency involves the facility’s failure to implement and document a physician’s order for a resident to wear a protective helmet when out of bed. The resident was admitted with epilepsy, traumatic brain injury with brain compression and herniation, anxiety disorder, mood disorder, and major depressive disorder. A care plan focus initiated in early June 2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included the intervention for the resident to wear a helmet out of bed. An active order dated June 6, 2023, and subsequent physician progress notes, including one dated January 9, 2026, directed that the resident wear a helmet when out of bed. A quarterly therapy screen and a quarterly MDS assessment showed no indication that the resident refused the helmet or that its use had been discontinued, and the MDS documented no rejection of necessary care in the seven days prior to that assessment. Despite these orders and care plan interventions, surveyor observations over multiple days showed the resident repeatedly out of bed and ambulating without the helmet. On the first survey day at 9:00 AM, the resident was observed standing in his room without a helmet, while the helmet was on the nightstand under a wall sign stating “HELMET ON AT ALL TIMES OUT OF BED.” The resident reported that staff had helped him apply the helmet in the past. Shortly thereafter, a nurse entered to administer medications and did not assist with helmet application, and the resident was observed walking out of the room without the helmet. On subsequent days, the resident was observed in the activities room, in the dining room, and walking out of the dining room without the helmet. During an interview, the resident described the extent of his traumatic brain injury, stated he needed to be careful with ambulation due to risk of re-injury, acknowledged awareness of the helmet signage, and stated that staff assisted him with helmet application when needed. The medical record lacked documentation that the helmet order was being implemented and lacked documentation of any refusals by the resident. An LPN who provided care to the resident stated she was unsure why the resident required a helmet, had not seen him wear it, and was unaware of the helmet order or the signage until it was pointed out; she confirmed that refusals of treatment should be documented on the MAR/TAR and communicated to the charge nurse, but could not locate a helmet treatment on the MAR/TAR. A CNA reported that the resident used to wear the helmet more frequently when first admitted but could not say why he stopped and assumed therapy had discontinued the order, though she had not been informed of any change. Later, the helmet signage in the resident’s room was found removed, and the charge nurse stated she did not know why it was taken down and believed therapy would discontinue such an order, yet there was no documentation of discontinuation in the record. The director of rehabilitation stated that therapy had assessed and educated the resident on helmet use, including modifications to make it easier to don and doff, and that the resident was discharged from therapy with the expectation that helmet use out of bed would continue and that floor staff would cue and assist as needed. She stated that any caretaker could apply the helmet and that discontinuation of such an appliance would be documented in the chart, which was not evident for this resident. The interim DON confirmed that the active order for helmet use out of bed had not been discontinued and that facility expectations were to follow physician orders as written, update care plans as needed, and document completion of orders and refusals so providers are aware. Facility policies on documenting and charting and on physician orders required complete documentation of care and accurate implementation and transcription of treatment orders into the eMAR/eTAR. The lack of implementation and documentation of the helmet order, and absence of documented refusals or discontinuation, constituted the deficiency.
Deficient Food Storage, Sanitation, and Temperature Control in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and sanitation practices in the facility’s dietary services. During an initial kitchen observation, food debris described as dry, crumb-like items was found under the bottom shelf in the dry storage area. The dietary manager acknowledged the debris and stated it could draw vermin, and reported that dishwashing staff are responsible for sweeping and mopping all floors after every meal, including the dry storage area. In the main kitchen refrigerator, surveyors observed an individual plastic cup of applesauce with a loosened snap-on lid open approximately 1/4 inch, three uncovered and undated sheet cakes on separate shelves, undated tubes of ground beef in original packaging, and an open, undated block of cheese exposed to air. In the freezer, three sheet trays containing a total of ninety uncovered burger patties were observed exposed to air, along with an opened and undated bag of frozen egg rolls. The dietary manager stated these practices could allow foodborne illness potential. Debris particles that appeared gray and wet were also seen on the rubber rims inside the ice machine when its door was lifted, and the dietary manager stated this area needed cleaning. On a subsequent observation of unit refrigerators, spilled liquid resembling yogurt was noted on the bottom shelf of the 500 wing refrigerator; the dietary manager stated that staff come daily at a set time to clean all unit refrigerators. During observation of the tray line, surveyors followed the last unit tray cart and recorded food temperatures taken by the dietary manager: chicken measured 120°F, mixed vegetables measured 115°F (with difficulty obtaining an accurate reading due to inability to maintain a discrete pile), and baked bread pudding measured 120°F. Later, the dietary manager stated that sweeping and mopping are done after lunch and at night, and that they do not clean after breakfast due to how busy they are at that time, while also stating he is responsible for overseeing completion of these tasks. The facility’s “Resident/Personal Food Storage” policy stated that food storage areas shall be clean at all times, which contrasted with the observed conditions in the dry storage area, refrigerators, freezer, and ice machine.
Failure to Notify Legal Guardian of Resident's Change in Condition
Penalty
Summary
The facility failed to honor a resident's rights by not notifying the court-appointed legal guardian of multiple changes in the resident's medical condition. The resident, who had diagnoses including acute on chronic congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, unspecified dementia, and dysphagia, was determined to have severely impaired cognition with a BIMS score of 6. Documentation confirmed the presence of a permanent legal guardian, and the resident's electronic medical record included the guardian's contact information. Despite this, there was no evidence that the legal guardian was notified of significant changes in the resident's condition, such as elevated INR, uncontrolled blood glucose, medication adjustments, new orders for diagnostic procedures, or care conferences. Multiple notes in the resident's medical record indicated that only the resident was notified of these changes, even though the resident was not cognitively capable of making informed decisions. Staff interviews confirmed that facility policy and staff understanding required notification of the legal guardian in such cases, regardless of the resident's wishes, due to the guardian's court-appointed authority. However, the documentation repeatedly showed that the legal guardian was not informed during several key events, including medication changes, new diagnoses, and care planning meetings. Facility policies reviewed stated that residents or their responsible agents must be informed of changes in condition and that legal guardians are to be involved in decision-making for residents deemed incapacitated. Despite these policies, the facility did not consistently communicate with the legal guardian as required, as evidenced by the lack of documentation of such notifications during multiple changes in the resident's condition and care.
Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
A resident with multiple complex medical conditions, including acute respiratory failure, MRSA infection, bacteremia, infective endocarditis, diabetes with foot ulcer, and congestive heart failure, was re-admitted to the facility with several unstageable pressure ulcers and diabetic foot ulcers. The care plan and physician orders specified daily wound care treatments for multiple wound sites, including the sacrum, heels, and feet, with specific instructions for cleansing, application of topical medications, and dressings. The resident's cognitive status was intact, as indicated by a BIMS score of 15. Despite these orders, documentation revealed that wound care treatments were not administered on multiple dates. The Medication and Treatment Administration Record (MAR/TAR) showed no evidence of wound care on certain days, and for several other dates, wound care orders were marked as "Hold/See Nurse Notes." Nurse notes indicated that the resident was often not in their room or on the unit at the time of scheduled treatments, or refused treatment, but there was no evidence that staff made follow-up attempts to provide care at a later time, coordinated with the resident for an alternate time, or communicated with the following shift to ensure treatments were completed. There was also no documentation of resident education regarding the importance of wound care or any modification of the care plan in response to missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to follow physician orders, attempt to locate the resident, and reschedule treatments if the resident was unavailable or refused at the scheduled time. However, the clinical record lacked evidence of these follow-up actions. Facility policies required that wound care be administered as ordered, documented at the time of administration, and that interventions be modified as needed based on the resident's condition. The failure to provide wound care as ordered and to document follow-up actions constituted a deficiency in the provision of necessary treatment and care.
Failure to Follow Physician Orders for IV Site Care
Penalty
Summary
The facility failed to provide treatment and services in accordance with physician orders and professional standards for a resident who required intravenous (IV) site care. The resident was admitted with multiple infections, including staphylococcal arthritis, methicillin susceptible staphylococcus aureus infection, cellulitis, and a cutaneous abscess. A physician order specified that all central line, PICC, and midline transparent dressings should be changed using sterile technique upon admission, every seven days, and as needed, with additional instructions for changing injection caps. The Medication Administration Record (MAR) indicated that the dressing change was documented as completed by a registered nurse on a specific date. However, during an observation, the IV site dressing was found to be dated prior to the resident's admission and had not been changed according to the physician's order. The dressing was identified as originating from the discharging hospital, and staff confirmed that it had not been replaced since admission. The Assistant Director of Nursing acknowledged that the order required the dressing to be changed every seven days and as needed, and that the MAR reflected a dressing change that had not actually occurred. Facility policy requires accurate implementation of physician orders, but in this instance, the order for IV site care was not followed.
Failure to Follow Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow the facility's infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors for infection. The resident had been admitted with diagnoses including staphylococcal arthritis, methicillin susceptible staphylococcus aureus infection, cellulitis, and a cutaneous abscess, and had a central line in place. Physician orders specified the use of EBP, requiring personal protective equipment (PPE) such as gown and gloves for high-contact care activities due to the presence of wounds and a central line. During an observation, the registered nurse entered the resident's room to disconnect an IV line and flush the central line, but only donned gloves and did not wear a gown as required by EBP protocols. The Assistant Director of Nursing confirmed in an interview that EBP should be applied for residents with central lines and wounds, and that staff are informed of these requirements through physician orders. Review of the facility's infection control policy further confirmed that both gown and gloves are required for high-contact care activities involving central lines or wounds.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse by other residents and visitors. Resident #49, who had severe cognitive impairment and wandering behaviors, was found with a facial bruise after an altercation with Resident #161, who also had severe cognitive impairment. The incident occurred when Resident #49 took Resident #161's wheelchair, leading to Resident #161 making contact with Resident #49's nose. The staff did not witness the altercation but found Resident #49 with a small amount of blood on her face and Resident #161 yelling about the wheelchair. Both residents were separated and assessed for injuries, and the incident was reported to the Administrator and DON immediately. In another incident, Resident #175, who had diagnoses including COPD, type II diabetes, and anxiety disorder, was hit on the back of the head by a visitor using a large black purse. The visitor was demanding her purse back from the resident, leading to an argument that escalated into physical abuse. The CNA witnessed the visitor hitting Resident #175, who sustained a small cut on the back of his head. The social services manager intervened, and the visitor was asked to leave and was subsequently banned from returning to the facility. A third incident involved Resident #216, who had intact cognition, and Resident #223, who had moderate cognitive impairment. Resident #216 was seen making closed-hand contact with the back of Resident #223 after an argument over a cigarette on the smoking patio. The CNA intervened and separated the residents. Resident #216 reported feeling threatened by Resident #223's swinging arms, which led to the physical contact. The facility documented these incidents as isolated events and took immediate action to separate and assess the residents involved.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to an elopement incident. The resident, who had a history of meningitis, sepsis, subperiosteal abscess of the mastoid in the left ear, pneumonia due to pseudomonas, chronic viral hepatitis C, and transient ischemic attack, was admitted with cognitive impairments and was not oriented to time, place, or person. Despite being ambulatory and having no wandering behaviors initially, the resident was identified as low risk for elopement. However, on a later date, the resident set off the front door alarm and was found missing after a head count. Staff observed the resident walking down a nearby avenue but were unable to catch up to him, and the resident refused to return to the facility. The Director of Nursing (DON) confirmed that the protocol for a missing resident involved searching the building and, if unsuccessful, calling the police to file a missing person report. The resident's public fiduciary, who had full guardianship, was not informed or did not consent to the resident leaving the facility. The facility did not have self-report documentation or witness statements for the incident. The public fiduciary confirmed that the resident exited through a fire exit door and refused to come back despite staff efforts to follow him.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to ensure that Resident #465 was free from abuse by another resident, Resident #464. Resident #465, who has a BIMS score of 13 and multiple diagnoses including metabolic encephalopathy and COPD, was physically assaulted by Resident #464, who has a BIMS score of 14 and diagnoses including rhabdomyolysis and mood disorder. The incident occurred when Resident #464 became upset with Resident #465 being in his room and kicked Resident #465, causing a skin tear on his right forearm. This incident was confirmed through interviews with staff and review of progress notes, where Resident #464 admitted to the assault and stated that he had threatened to kick Resident #465's ass before the physical altercation occurred. The incident was reported by Resident #465 to the Operations Manager and was further corroborated by a CNA who responded to the commotion in the room. Despite the facility's policy on abuse prevention, the Operations Manager could not recall the incident, and the Director of Nursing stated that the facility would file a report within 2 hours of any injury, whether serious or non-serious, to the State Agency. The facility's failure to protect Resident #465 from abuse by Resident #464 highlights a significant deficiency in ensuring resident safety and adherence to abuse prevention protocols.
Failure to Reconcile Post-Discharge Medications
Penalty
Summary
The facility failed to ensure that a resident had a reconciliation of post-discharge medications according to professional standards. Resident #613, who was moderately cognitively impaired, was discharged with medications that were not prescribed to her. The discharge documentation indicated that the resident was to be discharged with her current medications, but she was given blister packs containing medications belonging to three other residents. This included medications such as Diltiazem, Atorvastatin, and Apixaban, which were not prescribed to Resident #613. Interviews with staff revealed that the process for discharging residents involved printing out a medication sheet and physically gathering the medications to be given to the resident. The discharge nurse was responsible for verifying that the medications matched the discharge summary. However, this verification process failed, resulting in Resident #613 being discharged with inappropriate medications. The Director of Nursing acknowledged that the manual process posed a risk of such errors occurring. The facility's policy required a reconciliation of all pre-discharge medications with the resident's post-discharge medications, but this was not adhered to in this case. The failure to properly reconcile and verify the medications led to Resident #613 being discharged with medications that could potentially cause harm, such as Cardizem, which can lower heart rate if not required by the patient. The incident was reported by the resident's daughter, who found medications labeled with other residents' names in her mother's possession.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Care Nursing Center | 0.3 mi | ★★★★★ | 9 | 0 |
| North Mountain Medical And Rehabilitation Center | 2.2 mi | ★★★★★ | 2 | 0 |
| Beatitudes Campus | 3.5 mi | ★★★★★ | 5 | 0 |
| Horizon Post Acute And Rehabilitation Center | 3.9 mi | ★★★★★ | 3 | 0 |
| The Terraces Of Phoenix | 4.1 mi | ★★★★★ | 0 | 0 |
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