Corona Regional Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the Interdisciplinary Team (IDT - a collaborative group of diverse healthcare professionals who work together to create and implement a unified, comprehensive care plan for a resident) notes accurately reflected the residents' current status for one of three residents reviewed (Resident 1), when discrepancies were found in Resident 1's IDT Notes.This failure had the potential to lead to improper care planning and inaccurate communication between disciplines.Findings:On February 11, 2026, Resident 1's medical record was reviewed.Resident 1 was initially admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (medical condition where the lungs cannot get enough oxygen into the blood) with hypoxia (low blood oxygen levels), tracheostomy (surgical opening in the neck to breath), and dependence on respiratory ventilator (inability to breath independently requiring mechanical assistance to get air in and out of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided meet professional standards of practice, for one of one resident reviewed (Resident 39), when the Licensed Vocational Nurse (LVN) did not check the NGT (nasogastric tube - a flexible tube inserted through the nose and down the throat into the stomach) placement prior to medication administration. This failure had the potential for Resident 39 to develop aspiration pneumonia (a lung infection that occurs when food, liquid, or objects are inhaled into the lungs causing inflammation and fluid build-up). Findings: On May 21, 2025, at 11:23 a.m., a concurrent medication administration observation and interview was conducted with the LVN. The LVN was observed to prepare Resident 39's medications and checked the arm band to verify her identity. The LVN stopped the feeding, attached a 60 ml (milliliter - a unit of measurement) syringe into the NGT and tried to aspirate for gastric residual (stomach contents). There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 15 vials of Ativan (medication used to treat anxiety disorders) two (2) mg (milligram - a unit of measurement) was not stored beyond the manufacturer's recommended discard date during an inspection of the medication refrigerator in the medication storage room located in the main building. This failure had the potential for a resident to receive an expired and ineffective medication. Findings: On [DATE], at 2:12 p.m., a medication storage room inspection was conducted with the Nurse Manager (NM). One vial of Ativan 2 mg with an expiration date of [DATE], was found stored in the medication refrigerator in the medication storage room located in the main building. In a concurrent interview with the NM, she stated any expired medication should be removed from use to prevent a licensed nurse from administering to a resident. On [DATE], at 3:18 p.m., the Director of Nursing (DON) was interviewed. The DON stated the staff checked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to a vulnerable facility population. Findings: On May 19, 2025, at 7:15 a.m., an initial tour of the kitchen was conducted with the Director of Nutritional Services (DNS). Two fruit cups labeled with a use-by date of May 18, 2025, were observed in the refrigerator, readily available for use. One fruit cup with no label or date was also observed in the refrigerator, readily available for use. On May 19, 2025, at 7:15 a.m., a concurrent interview and record review was conducted with the DNS. The DNS stated all items stored in the refrigerator should have a use-by date. The DNS stated the one fruit cup with no label or date should not have been stored in the refrigerator, readily available for use. The DNS stated the two fruit cups should have been discarded on or before the expiration date (use-by date), and not stored in the refrigerator, readily available for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure infection control practice was implemented when the Licensed Vocational Nurse (LVN) did not properly clean and disinfect shared glucometer (measures the amount of glucose [sugar] in the body) in accordance with the disposable wipe manufacturer's specified contact time (contact time/wet time - amount of time a disinfectant needs to stay visibly wet on a surface to effectively kill germs). This failure had the potential to expose the resident to cross-contamination and development of infection. Findings: On May 21, 2025, at 12:08 p.m., during a medication administration observation with the LVN, the LVN was observed using a shared glucometer. The LVN was observed to wipe the glucometer with a Sani cloth disposable wipe (used to clean, sanitize and disinfect hard, non-porous surfaces [does not allow liquid or air to pass through it])) then proceeded to check Resident 18's blood sugar. The LVN was observed to wipe the glucometer with a Sani cloth disposable wipe but did not follow the manufacturer's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions of turning and repositioning of dependent residents, for one of four residents (Resident 1), who had the potential for the development of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed the resident at an increased risk for developing and/or worsening of pressure injuries. Findings: On April 2, 2024, at 10:17 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On April 2, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute and chronic respiratory failure (unable to breath without difficulty) post tracheostomy (an artificial opening in the trachea to allow oxygen to the lungs), quadriplegia (inability to move all four extremities), and intracranial hemorrhage (bleeding in the brain). The physician History and Physical indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time Registered Dietitian and/or a full-time Director of Food Services in accordance with California Code, Health and Safety Code - HSC § 1265.4 The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in inadequate supervision leading to food borne illness for seven residents who received food from the kitchen out of a facility census of 58. Findings: During the Federal re-certification survey from February 12, 2024 - February 15, 2024, it was noted that Food and Nutrition services provided meals not only to skilled nursing residents but also to a separately licensed, Behavioral unit. The skilled nursing facility's Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS) were working in 3 different facilities, Acute Hospital, Skilled Nursing facility (SNF) and Behavioral unit. Review of the organizational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. The Director of Nutritional Services and the Nutritional Service Manager did not instruct food service workers to follow manufacturer guideline for monitor temperature on dish machine. 2. The cook used wrong scoop plated lunch meal on February 13, 2024, for four residents (Residents 2, 19, 30, and 54). (Cross reference 803) These failures had the potential for unsafe food practices which may lead to foodborne illness (stomach illness acquired from ingesting contaminated food), and the potential to not meet the nutritional needs of the residents in a medically vulnerable population of seven out of 58 sample residents who received food prepared in the kitchen. 1. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Annex 3: Section 4-204.115 Warewashing Machines, Temperature Measuring Devices, the FDA Food Code indicated, The requirement for the presence of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of five residents (Residents 2, 19, 30, and 54), was met for lunch, when the meal was not plated in accordance with menu guidance for lunch. This failure had the potential to result in under or over nutrition. When a resident receives foods that are not consistent with their physician ordered diet, it may result in further compromising the resident's medical status. Findings: During an observation of the lunch meal plating on February 13, 2024, at 11:53 a.m., the [NAME] (CK) used a green scoop, 2.5 ounce (oz.- a unit of measure), for broccoli and rice instead of a grey scoop, 4 oz. per the menu and diet orders. During an interview on February 13, 2024, at 2:30 p.m., with Nutritional Service Supervisor (DSS) and Director of Nutritional Services (DRD), were asked to explain the scoop colors and the size. They explained the green scoop is 2.5 oz. and the grey scoop is four oz. or equal to 1/2 cup. DSS and DRD explained that if the wrong scoop size was used to plate the food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when : 1. The Prep sink did not have an air gap; 2. Nine cutting boards surface were heavily marred; 3. Three storage silver shelves in trayline area had rust; 4. Two microwaves in the kitchen were dirty; 5. Lacked temperature monitor for Prep table refrigerator; 6. Multiple areas in the kitchen were covered with dust; 7. The walk in refrigerator's gasket was wore out; 8. Unsanitary storage condition in walk in refrigerator; 9. Multiple areas in the kitchen's floor did not have smooth surface; 10. Trash were found in the multiple areas in the kitchen; 11. Build up grease and black/brown debris found on fire suppression unit above stove and fryer; 12. Cobweb found in dry storage room; and 13. Under the grill/stove range there was burn buildup material and black particles. These failures had the potential to cause foodborne illness (stomach illness acquired from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when trash was found on the ground surrounding the trash compactor, and the trash was piled up above the fill rim of the trash compactor. This failure had the potential to attract rodents and insects which could place residents at risk for cross contamination (the process by which bacteria are unintentionally transferred from one substance or object with harmful effect) and foodborne illness (illnesses cause from ingestion contaminated food). Findings: During an observation and interview of Foodservice Worker (FSW), on February 13, 2024, at 2:00 p.m., the FSW was observed taking trash to the trash compactor located in the parking lot at the back of the facility. Bags of trash were seen above the trash compactor fill line, and loose trash (gloves, glass bottles, paper) on the ground around the compactor. One clear, plastic trash bag was hanging over the side of the trash compactor with a yellow liquid in it. There was a strong odor around the compactor. The FSW stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan for the monitoring of resident's edema (a swelling caused by too much fluid trapped in body's tissues) for one of one resident reviewed (Resident 161). This failure resulted in Resident 161's edema not being assessed by licensed staff from February 10, 2024 to February 12, 2024, which increased the potential for Resident 161 not to receive the proper care and treatment timely. Findings: On February 12, 2024, at 11:31 a.m., Resident 161 was observed lying in bed with eyes open. Resident 161 did not perform eye tracking during a verbal command. Resident 161 was observed with a tracheostomy (an opening in the windpipe to allow air to fill the lungs) tube, a gastrostomy tube (a feeding tube used to deliver a formula through the stomach), and on a respirator (a life-support machine). Resident 161 was observed with swelling on both arms and feet. Resident 161's arms were positioned on his sides without support and his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the enteral formula (EF - a form of nutrition that is delivered into the stomach as a liquid) was labeled with the date and time for one of six residents (Resident 45) receiving enteral formula. This failure had the potential for Resident 45 to experience complications from the formula, such as nausea, diarrhea, or infection. Findings: On February 12, 2024, at 9:50 a.m., Resident 45 was observed in bed with enteral formula feeding being delivered via pump. The EF container was observed with a blank label (no date and time of when it was hung.) On February 12, 2024, at 11:03 a.m., a concurrent observation and interview with Registered Nurse (RN) 1 was conducted. RN 1 observed Resident 45's EF container and stated the formula should be labeled and dated with the time once opened. RN 1 stated there was no way to tell when the EF was hung. RN 1 stated the risk of not dating the EF was that the resident could get an upset stomach, have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control prevention when Registered Nurse (RN) 3 did not wear gloves while handling a gastrostomy tube (G-tube - a tube inserted into the stomach to provide nutrition) for one resident (Resident 38). This failure had the potential to expose the vulnerable resident to infection. Findings: On February 14, 2024, at 11:31 a.m., Resident 38 was observed in bed. Resident 38 had a G-tube for nutrition and was receiving her medications via G-tube. On February 14, 2024, at 11:31 a.m., during the medication administration observation, RN 3 was observed handling the G-tube of Resident 38 without gloves. On February 14, 2024, at 12:30 p.m., an interview was conducted with RN 3. RN 3 confirmed she did not wear gloves when handling Resident 38's G-tube. RN 3 stated she should have worn gloves while handling Resident 38's G-tube. On February 14, 2024, at 12:30 p.m., a concurrent interview with the clinical manager (CM) 1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow the responsible party's declination for the COVID-19 vaccine for one of three residents, (Resident 1). This failure denied Resident 1's responsible party, (RP) to exercise her rights on behalf of Resident 1. Findings: On February 1, 2024, at 9 a.m., a telephone interview was conducted with Resident 1 ' s family member (FM). The FM stated she was the translator for Resident 1's responsible party (RP). The FM stated that in December 2023, while visiting with Resident 1, a nurse came into the room and asked if they wanted Resident 1 to have the COVID vaccine. The FM stated that the RP told the nurse no vaccinations. The FM stated that she went to the nurses' station and informed the staff that they did not want Resident 1 to have any vaccines. The FM stated the next day the RP received a phone call from the facility staff stating that Resident 1 had no adverse events from the COVID vaccine. The FM stated that the RP was very upset that Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation of abuse, to the state survey agency, ombudsman, and local law enforcement, within two hours for one of three residents (Resident 1). This failure had the potential to result in the delay of investigation and implementation of corrective action for Resident 1. Findings: On February 1, 2024, at 9 a.m., a telephone interview was conducted with Resident 1's family member (FM). The FM stated that she was translating for the responsible party (RP). The FM stated that Resident 1 complained of pain in the back of his head approximately two weeks ago. The FM stated that Resident 1 made a fist and stated he was punched in the head. The FM was unaware if the facility staff knew about the allegation. On February 7, 2024, at 11:30 a.m., an unannounced visit to the facility for a complaint investigation was initiated. A review of Resident 1's medical records indicated he was admitted on [DATE], from a local general acute care facility with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.