Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Villa Coronado D/p Snf during CMS and state inspections, most recent first.
Multiple deficiencies were identified in food safety and sanitation practices, including failure to perform hand hygiene upon entering the kitchen, improper cleaning of a thermometer probe, and inadequate labeling, dating, and removal of expired or damaged food items from storage. These actions did not comply with facility policy or FDA Food Code requirements.
A resident with paraplegia and neurogenic bladder was observed with a urinary drainage bag hanging at waist level on the bedside rail, with the catheter tubing looped back toward the resident, instead of being secured below bladder level as required. Clinical staff confirmed the drainage bag should have been placed lower to prevent complications, in accordance with facility policy.
Two residents with severe pain did not receive appropriate pain management. One resident with a pressure injury and paraplegia was given a lower dose of pain medication than prescribed for severe pain, while another with discitis and osteoarthritis had ongoing severe pain that was not reported to the physician after reassessment, despite facility policy requiring such notification.
A licensed nurse failed to complete the full two-hour abuse training required by facility policy, attending only a one-hour session. This lapse was confirmed by staff interviews and record review, with no evidence of the remaining hour being completed. The deficiency had the potential to impact resident care.
A resident with multiple diagnoses was prescribed several medications, including off-label use of Trazodone. The consultant pharmacist repeatedly identified medication regimen irregularities and made recommendations, but these were not consistently addressed or documented by nursing or the physician. The facility's MRR binder was incomplete, and required documentation and follow-up actions were lacking, contrary to facility policy.
A deficiency was identified when a trash can with a hanging urine container was found on a bedside table next to a resident's drinking cup. The resident had HIV and impaired mobility. Staff acknowledged that this placement was inappropriate and could result in contamination, contrary to infection control guidelines.
The facility failed to ensure food safety by leaving an ice machine bin open, risking contamination, and serving breakfast trays without documenting food temperatures. The GM and EC acknowledged these lapses, which violated facility policies on ice handling and food temperature documentation.
The facility failed to prevent infection spread due to lapses in PPE use and hand hygiene. Family members of a resident were not informed about PPE requirements, and a staff member entered a contact precaution room without PPE. Additionally, the staff member did not sanitize a medication container after use in an isolation room and failed to perform hand hygiene when changing gloves. These actions were contrary to the facility's infection control policies.
A resident did not have a splint applied as ordered, which was necessary to maintain their range of motion. The CNA responsible was behind on work and had not applied the splint, while the LN confirmed that nurses should ensure compliance with physician orders. The unit manager expected staff to follow these orders, as outlined in the facility's guidelines.
The facility failed to prevent a fall for a resident with Traumatic Brain Injury when a staff member did not follow a provider's order for bed rail positioning. Additionally, the facility did not conduct an elopement risk assessment for another resident with a history of depression and stroke, who left the facility unsupervised. The facility's policies did not adequately address these issues.
A facility failed to administer medications separately via feeding tube for a resident, risking medication ineffectiveness and tube clogging. A nurse combined medications and water flushes in a syringe, contrary to policy. Interviews confirmed the nurse's awareness of the correct procedure, which was not followed.
Food Safety and Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen as required by facility policy and professional standards. One kitchen staff member entered the kitchen without performing hand hygiene and proceeded to handle both dirty and clean items, including trays and cups, without washing her hands. This was observed by the Food and Dietary Manager, who confirmed that handwashing should have occurred upon entering the kitchen and between handling soiled and clean items, as outlined in both the facility's policy and the 2022 US FDA Food Code. Another deficiency was observed when a different kitchen staff member used an improper method to clean and sanitize a thermometer probe after checking the temperature of cooked fish. Instead of using thermometer wipes or a sanitizer specifically intended for thermometer probes, the staff member dipped the probe into a sanitizer bucket meant for cleaning kitchen surfaces and wiped it with a towel. Both the Registered Dietitian Operations Manager and the staff member acknowledged that this was not the correct procedure and could lead to cross-contamination, as the sanitizer in the red bucket was not intended for food-contact equipment. Additional issues were found in the storage and labeling of food items. Several dry storage food items were not labeled or dated, and dented canned goods were not removed from storage. There were also expired food items present in both the dry storage and refrigerator areas. The Food and Dietary Manager confirmed that all stored food should be labeled, dated, and that expired or damaged items should be discarded according to facility policy and the FDA Food Code. These failures in food storage and handling practices exposed residents to the risk of consuming contaminated or unsafe food.
Improper Positioning of Urinary Drainage Bag and Catheter Care
Penalty
Summary
The facility failed to ensure proper positioning of a urethral catheter and urinary drainage bag for a resident with paraplegia and neurogenic bladder. Upon observation, the resident's urinary drainage bag was found hanging on the bedside rail at waist level, with the catheter tubing looped back toward the resident, rather than being secured below the level of the bladder as required. Clinical staff acknowledged during interviews that the drainage bag should have been placed below the bedside rails to prevent urine from flowing back into the bladder. The facility's policy also indicated that catheter care requires securing the drainage bag and tubing below the level of the bladder.
Failure to Provide Effective Pain Management for Residents with Severe Pain
Penalty
Summary
The facility failed to provide effective pain management for two residents with significant pain-related diagnoses. One resident with a coccyx pressure injury and paraplegia reported that the pain medication administered by the facility was ineffective. Review of physician orders showed that this resident was prescribed Norco 5-325 mg for moderate pain and Norco 10-325 mg for severe pain. However, when the resident complained of severe pain, only the lower dose of Norco 5-325 mg was given, contrary to the physician's order for severe pain. Another resident with severe discitis and osteoarthritis also experienced issues with pain management. This resident was prescribed Roxicodone 5 mg for moderate pain and Roxicodone 10 mg for severe pain. When the resident reported severe pain, the correct dose of Roxicodone 10 mg was administered, but a reassessment shortly after showed the pain remained severe. The licensed nurse did not notify the physician about the unrelieved severe pain, as required by facility policy. Both incidents were acknowledged by facility clinical leadership as failures to follow physician orders and internal protocols for pain management.
Incomplete Abuse Training for Nursing Staff
Penalty
Summary
A licensed nurse did not complete the required two-hour abuse training within the designated calendar year, as evidenced by attendance at only a one-hour classroom session. This was confirmed through interviews and record reviews with facility staff, including the Senior Specialist and Staffing Manager, who acknowledged the missing hour of training. The facility's policy mandates semi-annual abuse training sessions for nursing personnel, but there was no documentation indicating that the nurse completed the full requirement. The failure to ensure completion of the mandated abuse training had the potential to affect the care and treatment of residents.
Failure to Address and Document Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that irregularities identified by the consultant pharmacist during the monthly drug regimen review (MRR) were addressed in a timely manner and consistently documented in the medical record for one resident. The pharmacist's written recommendations and communications, which included concerns about off-label medication use, opioid tapering, and clarification of medication orders, were either not responded to, responded to with insufficient detail, or not documented in the resident's medical record. The MRR binder was also found to be incomplete and not readily available, with missing lists of reviewed residents and incomplete written reports. The resident involved had diagnoses including psychosis and Down Syndrome and was prescribed multiple medications, such as Trazodone for insomnia and Aripiprazole. The pharmacist repeatedly noted the need for documentation of off-label use rationale for Trazodone, evaluation of opioid use, and clarification of other medication orders. Despite these repeated recommendations, there was a lack of clear response or documentation from nursing or the physician, and actions taken were either not specified or not recorded in the resident's chart. During an interview, the clinical manager acknowledged that the MRR reports and binder were not complete or readily accessible, and that the pharmacist's communications were not properly addressed or documented. Facility policy required timely review and response to pharmacist recommendations, as well as maintenance of complete records, but these procedures were not followed in this instance.
Improper Placement of Urine Container and Trash Can Near Resident's Personal Items
Penalty
Summary
A deficiency occurred when a trash can with a hanging urine container was observed placed on a bedside table, in close proximity to a resident's drinking tumbler. The resident involved had diagnoses including HIV and impaired mobility. During observation and interviews, facility staff acknowledged that the trash can and urine container should not have been placed on the bedside table or near the resident's personal items, as this could lead to contamination. Review of CDC guidelines confirmed that proper handling and separation of patient care equipment and personal items is required to prevent infection.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and service of food, as observed during a survey. The first issue involved an ice machine bin with its lid left open, exposing the ice to potential contamination. This was noted during an observation with the General Manager, who acknowledged that the lid should be kept closed to prevent contamination. The facility's policy on ice handling, effective from March 1, 2024, mandates that ice containers be properly covered to prevent disease transmission. The second issue was related to the serving of breakfast trays without proper documentation of food temperatures. During an observation with the Executive Chef, it was found that the temperature log for the served foods was blank. A staff member stated that temperatures were checked but recorded on a misplaced piece of paper instead of the official log. The Executive Chef confirmed that it was unsafe to serve food without documented temperatures, as it could lead to foodborne illness. The facility's policy, revised in April 2022, requires that food temperatures be documented on the temperature log before service, with specific temperature requirements for hot and cold foods.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure the prevention and spread of infection in several instances. Family members of Resident 80 were observed not wearing Personal Protective Equipment (PPE) while in a room requiring such precautions. Despite a sign indicating the need for PPE, the family members were not informed by the staff, specifically Licensed Nurse 11, about the necessity of wearing PPE when touching the resident. This oversight was acknowledged by LN 11, who admitted it was his responsibility to educate visitors about PPE requirements. In another instance, a staff member, LN 7, entered a resident's room under contact precautions without wearing PPE. LN 7 justified his actions by stating he did not touch anything in the room, but later acknowledged the importance of wearing PPE in such situations. Additionally, LN 7 was observed administering medication in a contact isolation room and returning the unsanitized medication container to the medication cart, which he admitted should have been sanitized to prevent infections. Furthermore, LN 7 was observed not performing hand hygiene before and after changing gloves during medication administration. The Infection Preventionist Nurse and Unit Manager 1 both emphasized the importance of wearing PPE and performing hand hygiene to prevent the spread of infection. The facility's policy on standard and transmission-based precautions clearly outlined the need for PPE and hand hygiene, which were not adhered to in these instances.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a splint was applied as ordered for a resident, which was necessary to maintain or improve the resident's range of motion. The resident, who was admitted to the facility on an unspecified date, was observed without the required splint on their left hand, despite a physician's order indicating it should be applied daily from 8 A.M. to 10 A.M. A sign above the resident's bed also indicated this requirement. During an observation, the resident was found with both arms propped on pillows, and no splint was visible. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident had not applied the splint as she was behind on her work. The Licensed Nurse (LN) confirmed that while CNAs were responsible for applying splints, nurses should ensure compliance with physician orders. The unit manager also stated that both CNAs and LNs were expected to follow the physician's orders for splints, which were necessary to maintain the resident's range of motion and muscle tone. A facility guideline issued in October 2022 outlined the procedure for applying splints as ordered by a physician.
Failure to Prevent Fall and Conduct Elopement Assessment
Penalty
Summary
The facility failed to prevent a fall for Resident 20 when a staff member did not adhere to a provider's order. Resident 20, who was admitted with diagnoses including Traumatic Brain Injury and quadriparesis with spasticity, was observed on two occasions lying diagonally in bed with his head and feet at opposite corners. A Licensed Nurse confirmed that the fall occurred because a bed rail was left down, contrary to the provider's order for all four side rails to be up with padding. The facility's fall prevention policy was reviewed, but a specific policy requiring staff to follow provider orders was not provided. Additionally, the facility did not perform an elopement risk assessment for Resident 78, who had a history of depression and stroke with left-sided paralysis. Resident 78 was found to have left the facility unsupervised and returned after a few hours. Despite having a WanderGuard, there was no elopement risk assessment on record, and it was not included in the admission assessment. Interviews with staff revealed that an elopement risk assessment should have been conducted to ensure Resident 78's safety, but the facility's policy did not address the need for such an assessment.
Improper Medication Administration via Feeding Tube
Penalty
Summary
The facility failed to ensure proper administration of medications via feeding tube for one resident, leading to a potential risk of medication ineffectiveness and tube clogging. During an observation, a licensed nurse (LN 7) was seen preparing and administering medications for a resident with a feeding tube. LN 7 crushed four pills individually, mixed each with 10 ml of water, and used a 60 cc syringe to administer them. However, LN 7 did not wait for the first medication to be completely administered before adding a water flush and the second medication into the syringe chamber, contrary to the facility's policy. Interviews with LN 7 and a manager (MGR 1) revealed that LN 7 was aware that medications should be given separately with a water flush in between to prevent drug interactions and tube clogging. The facility's policy on enteral tube medication administration, effective since May 2023, also indicated that medications should be given separately and allowed to flow by gravity into the tube. This incident highlights a deviation from the established protocol, potentially compromising the resident's care.
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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 Coronado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Pauls Health Care Center | 2.8 mi | ★★★★★ | 9 | 0 |
| Balboa Nursing & Rehabilitation Center | 3.3 mi | ★★★★★ | 7 | 0 |
| Golden Hill Post Acute | 3.3 mi | ★★★★★ | 54 | 0 |
| Mission Hills Post Acute Care | 3.5 mi | ★★★★★ | 0 | 0 |
| Hillcrest Heights Healthcare Center | 3.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.