Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Ridge Skilled Nursing & Rehabilitation Ce during CMS and state inspections, most recent first.
A resident who was discharged and later tested positive for Legionella at a hospital was not properly followed up by facility staff. The IP Nurse received notification from the hospital but did not document the call, gather key details, or initiate required infection surveillance actions such as water testing or resident tracking. The case was not reported to the Health District, and the Administrator was not informed, contrary to facility policy.
A resident admitted with ESRD had a peripheral IV catheter observed in the right forearm, but the admission assessment did not specify the IV site location or purpose, and the medical record lacked evidence that a baseline care plan was initiated and completed for the IV access. The DON confirmed the resident was admitted with an IV line and that it should have been included in the baseline care plan.
A resident admitted with ESRD had a peripheral IV left in place without IV med orders or physician clarification, and staff found the dressing loose and the line dangling. Another resident with a peripheral IV for IV Venofer did not have the site rotated every 3 days as ordered. The facility also failed to document IV removal details for both residents, including time, site, reason, and communication, as required by policy.
A resident with chronic respiratory failure, COPD, and pneumonia was found connected to a nasal cannula while the oxygen tank attached to the wheelchair was empty and turned off. An RN confirmed the resident was supposed to receive 2 L O2 continuously, and a CNA stated the resident had been on 2 L O2 since admission. The resident’s care plan included oxygen therapy, but an RN later verified there was no active O2 order, despite the facility policy requiring a physician order before oxygen administration.
Failure to assess and treat severe pain: A resident admitted with multiple fractures reported severe pain, but the chart lacked evidence of timely pain assessments, orders for medication covering moderate to severe pain at admission, and documented non-pharmacological interventions. The resident continued to report pain after wound care and overnight, while an LPN gave acetaminophen despite pain above the ordered range and a later tramadol order was not documented as administered. The DON and Clinical Resource Nurse confirmed pain management policy was not followed and that the admitting nurse did not obtain adequate pain medication orders.
A resident with chronic respiratory failure, diabetes with neuropathy, and other diagnoses had a POLST showing DNR/allow natural death, but the form was not properly validated for verbal consent. The POLST had handwritten "verbal consent" notes, yet no witness options were circled, the signature line was unclear, and the DON confirmed the form lacked the two staff signatures required for a verbal DNR consent.
The facility failed to provide appropriate pain management for two residents by not administering pain medication as ordered for one resident and not performing a timely pain assessment for another. One resident with a history of severe pain and recent dosage increase continued to receive a lower dose, and staff did not clarify or document the change. Another resident was not assessed for pain upon admission, with the first assessment delayed until the next morning.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with Alzheimer's disease. Despite having a process for informed consent, the facility did not document consent for Buspirone, Mirtazapine, and Depakote, which were prescribed for anxiety and agitation. Interviews with staff confirmed the oversight, and the facility's policy requiring informed consent for such medications was not followed.
A resident with a history of false allegations reported being hit by a CNA during care. Despite the facility's documentation indicating the need for a Cares in Pairs program, staff were unaware of this requirement, and no care plan was implemented. The DON acknowledged the lack of a care plan, which was against the facility's policy.
The facility failed to develop baseline care plans for two residents using medical devices. One resident, admitted with a soft collar after neck surgery, did not have a care plan for the collar's management. Another resident, with a leg fracture, lacked a care plan for an ACE wrap and CAM boot. An LPN confirmed these omissions, and the DON acknowledged the need for such plans. The facility's policy requires baseline care plans within 48 hours of admission, but these were not documented, leading to a deficiency.
A facility failed to document and apply TED stockings for a resident with heart failure and hypertension, as per their care plan and physician's orders. The resident was observed without the stockings, and the MAR showed missing documentation for several days. The ADON confirmed the lack of documentation and the absence of a specific policy for TED stockings, highlighting a deficiency in care plan execution.
The facility failed to manage medical devices and post-operative care for two residents, leading to potential risks for discomfort and skin issues. One resident's soft collar was not removed or assessed since admission, lacking physician orders for its management. Another resident's boot device was not assessed, and follow-up with the orthopedic surgeon was delayed due to missing documentation. The DON acknowledged these deficiencies, highlighting a lack of communication and documentation in care plans.
A facility failed to document psychoactive medication side effects monitoring for a resident with anxiety disorder and schizophrenia. Despite physician orders requiring monitoring every shift for medications like Trazodone and Risperdal, the MAR lacked documentation for specific dates. The ADON confirmed the oversight, and the facility's policy on psychotropic medication use was not followed, resulting in a deficiency.
A medication cart was left unlocked and unattended by a nurse, posing a risk of unauthorized access. Additionally, a resident with dementia had an unapproved bottle of hydrogen peroxide at their bedside, which was not part of their prescribed medications. Staff confirmed the oversight and acknowledged the need for secure medication storage.
Failure to Document and Respond to Legionella Notification
Penalty
Summary
The facility failed to provide documented evidence of actions taken and follow-up after being notified that a discharged resident tested positive for Legionella at a hospital. The resident, who had diagnoses including cerebral edema, urinary tract infection, E. Coli, and required supplemental oxygen, was transferred to the hospital due to altered mental status and shortness of breath. Hospital testing confirmed a positive Legionella PCR result from a nasopharyngeal swab. The Infection Preventionist (IP) Nurse received a phone call from the hospital informing them of the positive result but did not document the conversation or ask for critical details such as the date of the positive test or whether the resident was symptomatic. After receiving the notification, the IP Nurse relayed the information to the DON and ADON and inquired about the last time the facility's water system was tested for Legionella, which was in February with negative results. The IP Nurse was told by the Maintenance Director that further testing would not be conducted due to the previous negative result. No further investigation, water testing, or resident tracking was initiated. The IP Nurse acknowledged that the conversation with the hospital should have been documented and that additional information should have been gathered to determine if the infection was healthcare-associated. Other staff, including the ADON, Clinical Resource, and Maintenance Director, confirmed that the information about the positive Legionella case was shared verbally but not documented or acted upon according to infection surveillance protocols. The Administrator was not made aware of the hospital's notification, and the facility did not report the case to the Health District as required. The facility's policy required ongoing surveillance and appropriate interventions for significant infections, but these steps were not followed in this instance.
Baseline Care Plan Not Completed for Resident Admitted With Peripheral IV
Penalty
Summary
The facility failed to ensure a baseline care plan was initiated and completed for a resident admitted with a peripheral IV access. Resident 3 was admitted and readmitted with diagnoses including end stage renal disease (ESRD). On 08/12/2025, surveyors observed the resident with a purple-colored single lumen peripheral IV catheter in the right inner forearm. The admission assessment showed the resident was admitted on the evening of 08/10/2025 with an IV line, but the site location and purpose were not specified. The medical record did not contain evidence that a baseline care plan was initiated and completed for the resident's peripheral IV line. The DON stated that the admission nurse must document the presence of IV access for residents admitted with one, confirmed that the resident was admitted with an IV line, and acknowledged that the peripheral IV was not included in the baseline care plan even though it should have been.
IV Line Orders, Site Rotation, and Removal Documentation Not Followed
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was deficient for three sampled residents. Resident 3 was admitted and readmitted with end stage renal disease and was found on 08/12/2025 with a purple single-lumen peripheral IV catheter in the right inner forearm. The admission assessment documented that the resident arrived with an IV line, but the purpose and site location were unspecified, and the admission orders did not include IV medication orders. The resident stated the IV had been inserted at the hospital for IV antibiotics, but the antibiotics had been changed to oral before discharge and the line had not been used since admission. Staff confirmed the dressing was loose and the IV was dangling, and the RN and DON stated clarification should have been obtained from the physician regarding whether the line should be maintained or removed because there were no IV medication orders. Resident 155 was admitted with diagnoses including right femur fracture and anemia and had peripheral IV access in the left hand with a dressing dated 08/07/2025. The resident stated the IV had been placed at the facility and was being used for medication administration. A physician order dated 08/07/2025 directed insertion of a peripheral IV in the right hand for IV Venofer and another order directed changing the peripheral IV every three days and as needed for infiltration. An LPN confirmed the resident's peripheral IV was not removed and placed at a different location on 08/10/2025 as ordered, and the medical record lacked documented evidence that the site rotation order was followed. The facility also failed to follow its peripheral IV removal documentation policy for Residents 3 and 155. A physician order dated 08/13/2025 discontinued the IV line for Resident 3, and the Infection Preventionist reported removing the right forearm IV around noon because it was loose and not flushing well, but did not notify the physician or document the procedure in the medical record. For Resident 155, staff reported the peripheral IV was removed by the floor nurse after lunch, but the record lacked documentation of the date and time, tolerance, removal site, reason for removal, or communication with the physician or oncoming shift as required by facility policy.
Empty Oxygen Tank and Missing Oxygen Order
Penalty
Summary
The facility failed to ensure a resident with chronic respiratory failure with hypoxia, COPD, acute kidney failure, and pneumonia received safe respiratory care when the resident was found connected to a nasal cannula with an oxygen tank attached to the wheelchair that was empty and turned off. The resident was admitted on [DATE], and on 08/12/2025 staff observed the resident on oxygen with the tank empty. An RN later confirmed the resident was supposed to be on two liters of oxygen continuously due to chronic respiratory failure and COPD and verified the tank was empty and turned off. A CNA stated the resident had been on two liters of oxygen since admission to the unit. The resident’s care plan documented oxygen therapy for COPD and chronic respiratory failure, with interventions to administer oxygen and breathing treatments as ordered by the physician. On 08/13/2025, an RN verified the resident did not have an active oxygen order and stated that an order for oxygen was required. The facility’s Oxygen Administration policy required verification of a physician’s order before oxygen administration.
Failure to Assess and Treat Severe Pain
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not done for a resident admitted with multiple fractures, including fractures of the left radius, left ulna styloid process, left orbital floor, left middle finger phalanx, and maxillary fracture. On admission, the resident was observed in bed with the left arm bandaged and in a sling, the right arm in a splint, and facial bruising around the left eye. The resident reported severe pain rated 8/10 and stated not knowing what pain medication had been ordered. A family member also reported the resident had received Percocet in the hospital, which had been effective, but it was not ordered at the facility. The record showed an admission assessment identified the resident as having current or recent pain and being at risk for pain, with care plan interventions to administer pain medications as ordered and monitor pain every shift. However, the medical record lacked documented evidence that the LPN completed a pain evaluation on the day shift when the resident later reported severe pain after wound care. The record also lacked documented evidence that pain medication to manage mild, moderate, severe, or very severe pain had been obtained by the admitting nurse upon admission. A physician order was present for acetaminophen 325 mg, two tablets every six hours as needed for pain 1/10 to 3/10, but there was no documented order available at admission for pain above 3/10. The record also lacked documented evidence that non-pharmacological interventions were offered or provided for pain on 08/12/2025. A physician order later directed staff to attempt non-pharmacological approaches such as repositioning, offering snacks or fluids, adjusting room temperature, and distraction, but the resident continued to report severe pain and poor sleep. A later order for tramadol 50 mg every eight hours as needed for moderate to severe pain was obtained, yet the record lacked documented evidence that tramadol had been administered after the order was received. Facility staff, including the DON and Clinical Resource Nurse, confirmed the resident was at risk for acute and worsening pain, that pain assessment and management policy was not followed, and that the admitting nurse did not obtain medication orders to cover moderate to severe pain.
Incomplete POLST Signature Validation for Verbal DNR Consent
Penalty
Summary
The facility failed to ensure a POLST form was witnessed and signed by two staff members to validate a verbal consent for DNR status for one resident. The resident was admitted and readmitted with diagnoses including unspecified mononeuropathy, chronic respiratory failure with hypoxia, and type 2 diabetes mellitus with diabetic neuropathy. The care plan documented a POLST-DNR status and that code status would be reviewed quarterly and as needed, and the electronic medical record also listed the resident as do not resuscitate. The POLST form documented do not resuscitate (allow natural death), and the words "verbal consent" were handwritten on both pages. However, the section for validating signatures had no options circled to identify who signed, the signature line contained two crossed-out writings and one illegible entry, and the printed name and date fields were blank. The DON stated that a verbal DNR consent on a POLST required two nurses to witness and sign the form and confirmed the form did not include the two required signatures. An LPN also stated that verbal consent for DNR status required two staff members to witness and sign the form.
Failure to Administer Pain Medication as Ordered and Timely Assess Pain
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for two residents by not administering pain medication as ordered and not performing timely pain assessments. For one resident with a history of lumbar fracture, long-term opiate use, and complex regional pain syndrome, the physician increased the Hydromorphone dosage from 4 mg to 6 mg every 4 hours due to ongoing pain that interfered with therapy and sleep. Despite the new order, the resident continued to receive the lower 4 mg dose until discharge, and there was no documentation that the increased dose was ever administered. Nursing staff did not discontinue the previous order or clarify the duplicate orders, and a pain assessment following the dosage increase was not completed as required by facility policy. Therapy staff documented that the resident experienced severe pain during therapy sessions and sometimes declined therapy due to ineffective pain management. Both the occupational and physical therapists confirmed that pain was a persistent issue and that the resident's participation in therapy was negatively affected by inadequate pain control. The Director of Nursing acknowledged that the physician's new order should have replaced the previous one and that staff should have followed the prescribed orders to manage the resident's pain effectively. For another resident admitted with a right femur fracture and multiple surgical incisions, the facility failed to perform a pain assessment upon admission as required by policy. The first documented pain assessment was not completed until the following morning, several hours after admission. The Director of Nursing and a registered nurse confirmed that the pain assessment was missing from the initial evaluation, which could have delayed identification and management of the resident's pain.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident, identified as Resident 1 (R1). R1 was admitted with diagnoses including a puncture wound, a fracture of the fibula, and Alzheimer's disease. The medical record indicated that R1 had a legal representative appointed as a power of attorney. Despite this, the facility did not document informed consent for the administration of Buspirone, Mirtazapine, and Depakote, which were prescribed for anxiety, agitation, and aggressive behavior. The medications were administered without documented evidence of informed consent, which is a regulatory requirement. Interviews with the Director of Staff Development, a Registered Nurse, the Assistant Director of Nursing, and the Director of Nursing revealed that the facility had a process in place for obtaining informed consent, which included explaining the medication's purpose, risks, benefits, and potential side effects to the resident or their representative. However, this process was not followed for R1, as confirmed by the Director of Nursing upon reviewing R1's medical record. The Consultant Pharmacist also confirmed the necessity of informed consent for these medications due to their psychotropic nature. The facility's policy on the use of antipsychotic medications required informed consent, which was not adhered to in this case.
Failure to Implement Care Plan After Alleged Abuse
Penalty
Summary
The facility failed to initiate a care plan after a resident alleged physical abuse by a staff member. The resident, who had a history of making false allegations, reported that a female CNA was rough during peri care and hit the resident on the forearm/hand. This incident was reported to the direct care staff and subsequently to the administrator. Despite the facility's documentation indicating the need to revise care plans to include the Cares in Pairs program, there was no evidence that this was implemented by the survey date. Interviews with facility staff revealed a lack of awareness regarding the Cares in Pairs requirement for the resident. An LPN and a CNA both stated they were not aware of the need for two caregivers during the resident's care, except during transfers. The DON acknowledged the absence of a care plan related to the incident and agreed that it would have been beneficial to document interventions to prevent recurrence. The facility's policy mandates a comprehensive, person-centered care plan within 21 days of admission, but this was not adhered to in this case.
Failure to Develop Baseline Care Plans for Medical Devices
Penalty
Summary
The facility failed to develop a baseline care plan for two residents, which included necessary interventions for medical devices they were using. Resident 244 was admitted with a soft collar device following cervical spine surgery. Despite the requirement for the collar to be worn continuously, the facility did not include care and management interventions for the collar in the resident's baseline care plan. This omission was confirmed by an LPN who noted that the plan should have included details such as a referral to the surgeon, wearing schedule, skin assessments, and hygiene instructions. Resident 250 was admitted with a right leg fracture and required an ACE wrap dressing and a CAM boot device. The facility did not develop a care plan for these devices, which was confirmed by an LPN. The baseline care plan should have included management instructions for the ACE wrap and CAM boot, including a wearing schedule, skin assessments, and follow-up with the orthopedic surgeon. The lack of a care plan for these devices was acknowledged by the Director of Nursing, who confirmed that interventions should have been included. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to address the resident's immediate health and safety needs. However, the medical records for both residents lacked documented evidence of such plans, leading to a deficiency in meeting professional standards of quality care. The absence of these care plans placed the residents at risk for discomfort and complications related to their medical conditions and devices.
Failure to Document and Apply TED Stockings
Penalty
Summary
The facility failed to ensure proper documentation and application of Thrombo-Embolus Deterrent (TED) stockings for a resident with heart failure and essential hypertension. The resident was observed without TED stockings, despite having a care plan and physician's orders specifying their use to manage dependent edema. The resident's medical records, including the Medication Administration Record (MAR), showed multiple instances where the application of the stockings was not documented or signed off by nursing staff. The Assistant Director of Nursing (ADON) confirmed the lack of documentation and was unable to provide justification for the missing entries. The facility did not have a specific policy for TED stockings, although there was a policy for heart failure management. The expectation was for nursing staff to document the completion of tasks as per physician's orders, which was not adhered to in this case, leading to a deficiency in the resident's care plan execution.
Deficiencies in Post-Operative Care and Device Management
Penalty
Summary
The facility failed to ensure proper care and management orders for medical devices and post-operative appointments for two residents, leading to potential risks for discomfort and skin integrity issues. Resident 244, who was admitted with a cervical disc disorder and post-surgical soft collar device, did not have the collar removed or the skin underneath assessed since admission. The medical record lacked documented evidence of physician orders for the collar's management, and the admitting nurse failed to transcribe necessary care orders, resulting in a delay in appropriate monitoring and care. Resident 250, admitted with a right tibia fracture and post-surgical boot device, also experienced deficiencies in care. The resident's boot device had not been removed for assessment since a week prior, and there was no communication regarding the ACE wrap, boot device, or post-operative appointment. The medical record lacked evidence of a scheduled follow-up with the orthopedic surgeon, and clarification orders for the ACE wrap and boot device were not obtained. Weekly skin checks were missed, and the facility did not know the resident's surgeon, leading to a significant delay in post-operative care. The Director of Nursing acknowledged the deficiencies, including the delay in post-operative appointments and missed skin checks. The facility's policies required immediate entry of care orders upon admission and regular skin assessments, which were not followed. The lack of communication and documentation regarding the residents' care plans and follow-up appointments contributed to the deficiencies observed by the surveyors.
Failure to Document Psychoactive Medication Side Effects Monitoring
Penalty
Summary
The facility failed to ensure that psychoactive medication side effects monitoring was documented for one of the sampled residents, Resident 3 (R3). R3 was admitted with diagnoses of anxiety disorder and schizophrenia and had multiple physician orders for monitoring the side effects of various psychoactive medications, including Trazodone, Venlafaxine, Risperdal, Seroquel, and Vistaril. These orders required monitoring for a range of side effects every shift, and the results were to be documented in the medication administration record (MAR). However, the MAR for R3 revealed that the monitoring of side effects for the listed psychoactive medications was not completed or signed off on specific dates in August 2024. There was no documented evidence in the MAR or progress notes explaining why the monitoring was not signed off. The comprehensive care plan for R3 included interventions to monitor and document side effects and effectiveness of the medications every shift, but this was not adhered to. The assistant director of nursing (ADON) confirmed the lack of documentation during a review of the medical record and was unable to provide additional evidence or justification for the unsigned monitoring orders. The facility's policy on psychotropic medication use, revised in July 2022, required monitoring for adverse consequences, but this was not followed in R3's case, leading to the deficiency.
Medication Security and Storage Deficiency
Penalty
Summary
The facility failed to ensure the security of medications, as observed with one of the six medication carts. A nurse left the medication cart unlocked and unattended while stepping away to the nursing station, leaving it vulnerable to unauthorized access. During this time, other staff members, including a Unit Manager, were present but did not secure the cart. The Unit Manager acknowledged the oversight and reminded the nurse of the importance of keeping the cart locked when unattended. Additionally, a resident was found with a bottle of hydrogen peroxide on their bedside table, which was not prescribed or included in their self-administration medication safety screen. The resident, diagnosed with senile degeneration of the brain and unspecified dementia, was unable to recall the origin of the hydrogen peroxide. Facility staff, including an LPN and the Assistant Director of Nursing, confirmed that the hydrogen peroxide should not have been at the resident's bedside, as it was not part of the resident's approved self-administered medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 542 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Henderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Health Care Of Henderson | 1.1 mi | ★★★★★ | 0 | 0 |
| Oasis Nursing & Rehab Of Green Valley | 2.4 mi | ★★★★★ | 20 | 0 |
| Green Valley Health And Wellness Suites | 2.6 mi | ★★★★★ | 24 | 0 |
| Sage Creek Post-acute | 2.8 mi | ★★★★★ | 9 | 0 |
| Tlc Care Center | 5.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Coronado Ridge Skilled Nursing & Rehabilitation Ce.
100% money-back within 48 hours.
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.