Coalinga Regional Medical Ctr Dp/SNF

Inspectors wroteBased on interview and record review the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in any part of the urinary system) for one of three sampled residents (Resident 1), when the facility staff did not schedule or follow up on a physician ordered specialty referral to the urologist (a medical doctor and surgeon who specializes in diagnosing and treating conditions of the urinary tract) for Resident 1's frequent UTI's for more than one year. This failure placed Resident 1 at risk for delayed diagnosis and frequent urinary tract infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from verbal, mental, and physical abuse for five of the ten sampled residents (Resident (Res) 2, Res 3, Res 4, Res 5 and Res 6 when:Certified Nursing Assistant (CNA) 2 and CNA 3 mocked, laughed and engaging in demeaning behavior towards Res 2. CNA 2 and CNA 3 did not change Res 3's soiled briefs and did not provide appropriate perineal care (cleansing of the genital and anal area essential for preventing infections, reducing odors, and maintaining skin integrity), or hygiene, failing to clean Resident 3 prior to changing Res 3's brief. CNA 3 struck Res 4 in the face with a chuck pad while cleaning a bowel movement, constituting physical abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident (Res) 1) received necessary care and services in accordance with professional standards of practice when:The facility staff failed to identify, assess, investigate, and document an unwitnessed fall reported by Res 1. Nursing staff did not initiate required post-fall protocols, including timely assessment, neurological checks, ongoing monitoring, and implementation of appropriate fall-related interventions in accordance with facility policy. The facility failed to ensure timely physician assessment, and implementation of physician-ordered interventions following the resident's complaint of pain and subsequent diagnosis of a right knee fracture. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate documentation and follow its policy and procedures titled Falls - Clinical Protocol and Charting and Documentation for two of six sampled residents (Resident 1 and Resident 2), when the Licensed Vocational Nurse (LVN) 1 did not complete the neuro-check (a focused assessment of the nervous system used to identify acute changes in an individual's functional status) on 11/17/25 and 11/18/25 for Resident 1 after an unwitnessed fall on 11/15/25, and the Director of Nursing (DON) did not complete IDT (Interdisciplinary Team; [...]

Inspectors wroteBased on observation interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of three sampled residents (Resident 1), when the licensed nurses did not change Resident 1's wound dressing every shift as ordered by the physician for two days and documented in the electronic medical record that the wound treatment was completed. This failure had the potential to result in delay in care, wound healing, and cause an infection from bacteria buildup.

Inspectors wroteBased on observation interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of three sampled residents (Resident 2), when the certified nursing assistants (CNA) did not document Resident 1's urine output every shift on 10/31/25, 11/1/25, 11/2/25, 11/5/25, 11/9/25, 11/10/25, 11/12/25. This failure had the potential to result in delay in care and cause an infection from not assisting Resident 2 with urine elimination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from abuse for one of four sampled residents (Resident 1), when on 7/13/25 the activity assistant (AA) 2 was physically and verbally aggressive toward Resident 1 during the smoking break. This failure resulted in verbal and physical abuse toward Resident 1 and placed Resident 1 in an unsafe living environment.

Inspectors wroteBased on interview and record review the facility failed to follow facility's policies and procedures and meet professional standards of quality for one of three sampled Residents (Resident 1), when staff did not document Resident 1's change of condition (COC) or Situation, Background, Assessment and Recommendation communication form (SBAR- communication tool that provides critical information and ensures that important details are clearly communicated) for a staff to resident allegation of abuse on 7/13/25. This failure had the potential to result in the inaccurate assessment of Resident 1, delay in care and was at risk for further abuse.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was identified on the daily staff posting. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to electronically submit the Payroll-Based Journal (PBJ) (staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one quarter of the 2025 Fiscal Year for the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure accuracy of documentation according to professional standards for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when the assistant director of nurses/minimum data set (ADON/MDS) nurse documented and electronically signed for the social services director (SSD) on 1/3/25 and 1/6/25 in Resident 1, Resident 2 and Resident 3 ' s multidisciplinary care conference (MCC-meeting that could consists of director of nurses, physician, dietary staff, therapy staff, social services, activities, resident and resident representative to discuss resident care) notes. This failure resulted in falsified documentation and could have caused delay in care resulting from the inaccuracy of the documentation for Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse and neglect for one of three sampled residents (Resident 1), when Resident 1 was left outside for approximately one hour without supervision and the temperature was 92 degrees Fahrenheit on 9/29/24. This failure resulted in Resident 1's body temperature to reach 101.1 degrees Fahrenheit (normal body temperature range from 97 degrees to 99 degrees Fahrenheit) and elevated heart rate of 136 beats per minute (normal heart rate for adults is between 60-100 beats per minute) and had the potential for Resident 1 to experience heat exhaustion, dehydration and/or sunburn of the skin.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a comfortable environment for one of 35 residents (Resident 12) when the room temperature, measured by the California Department of Public Health (CDPH) thermometer, in Resident 12 ' s room was 84 degrees Fahrenheit. This failure had the potential to result in dehydration (body does not have enough fluids) and heat exhaustion (body overheats and unable to cool itself) for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled in accordance with professional standards for 24 of 31 residents when medication blister packs (a type of packing used for resident medication) had orange and green stickers placed over the expiration dates. These failures placed residents at risk for being administered expired medications which may have no longer had the same efficacy and/or side effects.

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to competently care for 49 of 49 residents at the facility during day-to-day operations and emergencies. This failure had the potential for residents not to receive the services needed to achieve and maintain the highest practicable well-being during day-to-day operations and during an emergency.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a clean and homelike environment for three of three sampled residents (Residents 6, 147 and 19), when: 1. The door frame of Resident 6's Room had missing and chipped paint. 2. Ceiling tiles were peeling, paint missing from Resident 147's room. 3. Resident 19's wall had a TV bracket in place without a television (TV) for over one month, which Resident 19 complained to staff about not having a TV in her room. These failures had the potential to violate the residents' rights to have a clean, sanitary, and comfortable homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed professional standards of practice when: 1. Facility staff did not obtained consent for psychoactive medication (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behaviors), vaccinations (preparation to stimulate the body's immune response against disease), side rails and his Physician Orders for Life-Sustaining Treatment (POLST-a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) while lacking decision-making capacity for informed consent (healthcare provider educates a patient about risks, benefits and alternatives of an intervention and the patient must be competent to make voluntary decisions) for one of three sampled residents [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. There was one unwrapped frozen food item on the floor, under the food rack in the walk-in freezer. This failure had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents. 2. Residents' meal trays were reheated by staff, who were not trained on the proper method to safely reheat food for residents whose meal trays were held to be consumed at a later time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for one of two sampled residents (Resident 98), when the staff failed to answer Resident 98's call light in a timely manner. This failure resulted in Resident 98 urinating on himself and sitting in his urine for approximately 21 minutes. Resident 98 verbalized feeling felt frustrated, embarrassed, and helpless. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure kitchen staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, in accordance with professional standards for food service safety when one of two sampled kitchen staff (Cook 2) were not able to verbalize the appropriate method of the food cool down process. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit the Payroll-Based Staffing Journal (PBJ - staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters (fourth quarter) in 2023 (July 1, 2023 through September 1, 2023). This failure had the potential for resident's in the facility to not have staff to resident ratio necessary to provide safe and quality care and prevented the provision of complete and accurate direct care staffing information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: 1. One of two sampled Licensed Vocational Nurses (LVN 2) tested Resident 18's blood sugar and placed the contaminated (infected by contact) blood glucose (sugar) monitor (glucometer- device that measures blood glucose levels) into the medication cart drawer without being cleaned or disinfected. This failure had the potential to expose facility residents to blood borne pathogens (infectious microorganisms present in the blood). 2. One of three sampled residents, Resident 32's oxygen (a life-saving colorless, odorless gas) tubing was curled up on the floor. This failure was a potential trip and infection control hazard for Resident 32.

Inspectors wroteBased on observation, interview and record review the facility failed to keep one of three sampled Residents (Resident 1) safe, when Resident 1 eloped [left the facility unsupervised] from the facility and was missing for two hours. The facility failed to follow its policy and procedure titled, Wandering and Elopements, when it did not create a care plan or interventions for wandering/elopement for this resident. This failure resulted in Resident 1 eloping from the facility, being found two hours later and had the potential to cause harm even death to the Resident 1.

Inspectors wroteBased on interview and record review the facility failed to protect the rights of one of three residents (Resident 1), when Resident 1 asked to be sent to the hospital for worsening of his sinus issues and the licensed nurse (LVN 1) told him he had two options: one wait for the doctor to come in and assess him or leave to go to the hospital by himself against medical advice (AMA). This failure resulted in Resident 1 getting upset and feeling like he was not being treated appropriately so he left in his wheelchair (WC) and wheeled himself to the Emergency Department (ED) of the hospital next door. Resident 1 was admitted to this hospital with Sinusitis (sinus infection) and placed on antibiotics (medication used to treat infections) and prednisone (steroid used to decrease swelling).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (Residents 114, 112, 108) of 16 sampled residents when: 1. Resident 114 experienced an 8.7% weight loss within the three-month period and a 12.2% weight loss within the five-month period and the care plan did not address this situation. This failure resulted in Resident 114 to have an on-going severe significant unplanned weight loss for five months since admission to the facility. 2. Resident 112 did not have a care plan to address the 15.6% weight loss within the three-month period and the 13.2% weight loss within the four-month period. This failure resulted in Resident 112 to have an on-going severe significant unplanned weight loss for four months since admission to the facility. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 114) maintained acceptable parameters of nutritional status when: 1. Licensed nurses did not communicate two episodes of significant severe unplanned weight loss to the interdisciplinary team (IDT - members of the care team that include nurses, social workers, doctors, therapists, dietician and others). Licensed nurses documented Resident 114's weight loss of 8.6% between 5/7/21 and 8/6/21 and a weight loss of 10.2% between 5/7/21 and 10/1/21 and did not report this to the IDT and appropriate assessments and effective interventions were not implemented. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide outside services of Podiatry (DPM), Registered Dietician (RD), and Psychiatry for three (3) of sixteen (16) sampled residents and twenty-two (22) unsampled residents when: 1. A physician of podiatry was not contracted to provide services to the facility from 12/3/20 to 10/6/21. This failure resulted in podiatry services not being provided to Resident 117 and 109 as well as 22 other residents in need of podiatry physician evaluation. Resident 117 experienced pain, infection, and removal of the left great toenail and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown toenails, and infections. 2. A Registered Dietitian (RD) was not contracted to provide services to the facility from July 21, 2021 to August 19, 2021. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care and make necessary podiatry appointments for two of sixteen sampled residents (Resident 109 and Resident 117) diagnosed with Type 2 Diabetes Mellitus (disease with impaired response to insulin, elevated blood sugar, decreased blood circulation in the feet), who had ingrown toenails (condition in which the side of the toenail grows into the flesh), and infected (disease caused by bacteria with swelling, redness and pus) toenails, and twenty-two unsampled residents that required podiatry assessments and treatments. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs and biologicals according to professional standards of practice and facility policy and procedure when a multi-dose vial of tuberculin (TB) testing serum (injected under the skin to test for tuberculosis (infectious bacterial disease characterized by nodules in the tissue and lungs) opened 8/21/21 and expired 9/20/21 was in the refrigerator area designated for use; and a 1 liter bottle of [Brand 1.5] gastrostomy tube (tube surgically inserted in the abdomen for access to the stomach) enteral feeding formula which had expired 6/21 (expired 4 months prior) was on the shelf with other formulas designated for resident use; and 16 bottles of expired enteral feeding [Brand 1.0] and 6 bottles of expired enteral feeding [Brand 1.2] were stored inside the dry food storage room. [...]

Inspectors wroteBased on interview, and record review, the facility's administrative staff failed to provide effective oversight and necessary resources to ensure resident care and services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of nine sampled Residents (Resident 8, Resident 9, Resident 10, Resident 110, and Resident 118), when the facility did not implement elements from their initial certification survey plan of correction (POC) for F-tag 692. (Cross reference 692) This failure had the potential to result in nutritional needs not being met for Residents 8, 9, 10, 110 and 118.

Inspectors wroteBased on interview and record review, the facility failed to identify, develop and implement an effective QAPI (Quality Assurance and Performance Improvement- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. (Cross reference tag F-692) This failure had the potential to affect the quality of care, quality of life, services and safety of the facility's residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean and safe environment for all residents in the facility when: 1. The ice machine located in the Skilled Nursing Facility (SNF) Supply Room was observed to have pink and green substance and white residue and to not be in a sanitary condition; the ice machine manufacturer's instructions for cleaning were not followed for two of two ice machines. 2. Two of two staff members (Licensed Vocational Nurse- LVN 4 and Certified Nursing Assistant- CNA 5) were observed to not use standard hand washing procedures while exiting a contact isolation room. These failures had the potential to cause food born illnesses, transmission of communicable diseases and infections to all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for five (5) of 16 sampled residents (Residents 110, ,114, 117, 122, and 128) when: 1. Resident 114's MDS assessment for weight loss were not coded accurately. 2. Residents 110, 117, 122, and 128's MDS assessment for the influenza (A common viral infection that can be deadly, especially in high-risk groups) and Pneumococcal vaccines (Vaccine to prevent pneunomia (Infection that inflames air sacs in one or both lungs, which may fill with fluid.) were not coded accurately. 3. Resident 128's MDS assessment for falls since admit were not coded accurately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were followed in the kitchen when: 1. Proper procedures were not followed for cooling ambient (foods prepared at room temperature) foods. 2. The ice machine drainpipe located in the SNF supply room did not have an air gap. 3. The can opener blade was dirty. These failures had the potential to place the 31 residents who received food prepared in the facility kitchen at risk for foodborne illness.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure three of five sampled residents (Resident 110, Resident 117, and Resident 128) were offered and/or received the Pneumococcal vaccinations. The facility also failed to ensure one of five sampled residents (Resident 122) was provided the education to make an informed decision to accept the Pneumococcal vaccine. These failures placed the three residents (Resident 110, 117, and 128) at risk of becoming infected with pneumonia and took away one resident (Resident 122) right to make an informed decision because the education was not provided on the pneumonia vaccine before it was given.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light was within the reach of residents to call for staff assistance for three of 16 sampled residents (Resident 108, 110 & 128). These failures had the potential for Resident 108, 110, and 128 not being able to call for assistance if assistance was needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one of three sampled residents (Resident 108) for removal of an indwelling (tube left within a body organ) foley catheter placed after admission. This failure resulted in pain to Resident 108's penis and the potential harm of continued infection and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who use psychotropic (drug that effects brain activity) medications receive a Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or discontinued), for one of sixteen sampled residents (Resident 114). This failure placed Resident 114 at risk for prolonged use of psychotropic medication and increased risk for adverse medication side effects.

Inspectors wroteBased on observation, interview, and policy and procedure review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals served to the facility residents when one [NAME] (Cook 1) did not follow the facility menu, did not calibrate a food thermometer correctly, did not take food temperatures correctly, and did not know the correct thawing procedure when using the sink thawing method for meats. These failures had the potential to place the 31 residents who received food prepared in the kitchen at risk for foodborne illness and to not meet their nutritional needs which could lead to nutritional related health concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility menus were followed when: 1. High Calorie/High Protein (HiCal/Pro) diets were not followed for one sampled resident (Resident 112) and one nonsampled resident (Resident 115) out of 31 residents and, 2. The diet spreadsheet was not followed for all diets served in the facility. These failures posed the risk for 31 residents who received food prepared in the kitchen to not meet their nutritional needs.

Inspectors wroteThe facility failed to ensure one of 16 sampled residents' (Resident 118) food preferences were honored when: Resident 118 did not receive cranberry juice with her lunch meal as she requested. Resident 118 received milk with her lunch meal after informing the facility she did not like milk. This failure caused Resident 118 to not receive the beverage she preferred.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nutritional assessments were performed by a qualified Registered Dietitian for one of 16 sampled residents (Resident 114) when: The Dietary Manager failed to meet the qualifications and skill set to assess the facility's residents' nutritional status. This failure posed the risk for residents' nutritional needs to not be met.