Coronado Ridge SNF: Legionella Alert Ignored - NV
That's what inspectors found when they arrived on September 3, 2025, following a complaint. The administrator told them directly: they were not aware of the August 6 phone call from the hospital about the Legionella case. The hospital's own records tell a different story.
According to documentation from the hospital's Infection Preventionist, the facility was notified a second time on August 8 at 8:56 in the morning. The summary recorded the name of the hospital's infection prevention nurse and noted that Coronado Ridge had been contacted. Two calls. Eight days apart. Neither one, apparently, made it to the person running the building.
The facility's Maintenance Director couldn't fill in the gap either. Inspectors asked about the former resident, and the Maintenance Director said they didn't know who the resident was.
Legionella is a bacterium that causes Legionnaires' disease, a severe form of pneumonia. It spreads through water systems, including cooling towers, hot tubs, and the kind of large plumbing infrastructure found in institutional buildings. When a hospital contacts a nursing facility to report that a former resident tested positive, the implication is direct: that person was living somewhere before they got sick, and that somewhere needs to look at its water.
Coronado Ridge had a policy for exactly this situation. A document titled "Surveillance for Infections," dated September 2017, described the facility's infection preventionist as responsible for conducting ongoing surveillance for healthcare-associated infections and other epidemiologically significant organisms. The policy stated that the purpose of that surveillance was to identify individual cases and trends, guide appropriate interventions, and prevent future infections.
The policy existed. The calls came in. The investigation never started.
What the inspection report does not say is whether any current residents were tested, whether the facility's water system was ever evaluated, or whether anyone beyond the administrator and Maintenance Director was asked what they knew. The record ends where the facility's awareness apparently did: at the front desk, sometime before August 6.
Inspectors tagged the violation under F0880, the federal citation covering infection prevention and control. The level of harm was listed as minimal harm or potential for actual harm, with few residents affected. That classification reflects what inspectors could document, not necessarily what the missed notification might have set in motion.
The former resident who tested positive is identified in the report only as R1. The inspection report does not say when R1 was discharged from Coronado Ridge, how long they had been a resident there, or what their condition was when they left. The Maintenance Director's inability to identify who R1 was suggests the facility made no effort between August 6 and September 3 to connect the hospital's warning to any specific person in their own records.
That's four weeks.
A hospital called on a Wednesday in early August to say a person who had lived at this facility was now hospitalized with Legionella. Then they called again two days later on a Friday morning, this time with the facility's own infection prevention nurse named in the documentation. Somewhere between that Friday morning call and the afternoon of September 3, when an inspector sat across from the administrator and asked about it, the information disappeared.
The administrator said they weren't aware of it. The Maintenance Director didn't know who the resident was. The infection preventionist, whose name appears in the hospital's records as the point of contact for the August 8 notification, is not quoted in the inspection report.
Coronado Ridge's own surveillance policy described the infection preventionist's role as conducting ongoing surveillance and guiding appropriate interventions. Whether that person received the hospital's calls, passed them along, or acted on them in any way is not addressed in the three pages of inspection documentation made available.
What is documented is the outcome: a resident left this facility, contracted Legionella, ended up in a hospital sick enough that the hospital's infection control team opened a formal notification process and contacted Coronado Ridge twice. And when federal inspectors walked through the door a month later, the facility's leadership could not account for either call.
R1 was already gone by then, somewhere in a hospital, or recovered, or not. The inspection report doesn't say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Coronado Ridge Skilled Nursing & Rehabilitation Ce from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
CORONADO RIDGE SKILLED NURSING & REHABILITATION CE in HENDERSON, NV was cited for violations during a health inspection on September 3, 2025.
That's what inspectors found when they arrived on September 3, 2025, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.