Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coalinga Regional Medical Ctr Dp/snf during CMS and state inspections, most recent first.
Failure to Schedule Ordered Urology Referral: A resident with recurrent UTIs and moderate cognitive impairment had a physician-ordered urology referral that was not scheduled or followed up for more than a year. Staff interviews and EMR review showed nursing documented referrals for SS to schedule, but there was no evidence the resident ever saw a urologist before the deficiency was identified.
A resident with cognitive impairment was mocked and taunted by CNAs, while other residents reported being left unclean after brief changes and one resident was struck in the face with a chuck pad during care. Staff also reported delayed call light response and poor care from the same CNAs, and two residents were left unmonitored during activities in the dining room, where a physical altercation occurred with no staff present.
Failure to assess and document an unwitnessed fall with fracture: A resident with multiple chronic conditions reported slipping in urine and falling while trying to stand from a wheelchair, then developed severe R knee pain and a confirmed fracture. Nursing obtained an x-ray after the pain complaint, but the record lacked timely MD documentation, post-fall assessment, neuro checks, and evidence that ordered interventions such as a knee immobilizer, ice, and elevation were implemented or care planned. The resident’s care plan was not updated to reflect the fall, fracture, or increased fall risk, and staff described a marked decline in mobility and function after the injury.
Two residents experienced unwitnessed falls, and staff failed to complete required neuro checks and IDT documentation as per facility policy. One resident with multiple chronic conditions and moderate cognitive impairment was found on the floor after striking the head and shoulder; although the MD was notified and an ER evaluation ordered, the LVN did not complete the ordered neuro checks for two subsequent days, leaving vital signs, level of consciousness, pupil responses, and hand grips undocumented. Another resident with Alzheimer’s disease and severe cognitive impairment had an unwitnessed bathroom fall, with MD notification, neuro checks, and a head CT ordered, but the DON left the IDT post-incident meeting form largely blank, documenting only the date and time of the meeting and omitting details of the discussion, cause analysis, interventions, notifications, and new orders. These omissions resulted in incomplete medical records that did not fully reflect the care provided or the post-fall assessments required by facility policy.
A resident with a stage 4 pressure ulcer did not have wound dressings changed every shift as ordered by the physician, despite documentation in the electronic medical record indicating the treatment was completed. Observation and interviews confirmed the dressing had not been changed for two days, and staff acknowledged the documentation was inaccurate and did not reflect the actual care provided.
Certified nursing assistants did not consistently document a resident's urine output as required by facility policy and professional standards. Despite expectations for timely and accurate documentation after each episode of assistance with urination, the resident's bladder elimination record was incomplete on multiple days. This failure was confirmed by both an LVN and the DON during record reviews and interviews.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that care and services provided met professional standards of quality, as observed through practices that did not align with established guidelines.
The facility did not perform the mandated four-year inspection and testing of fire/smoke dampers in the HVAC system, as staff mistakenly believed the testing schedule matched that of the Main Hospital Building. This oversight affected all residents and both smoke compartments, with no current inspection records available.
The facility did not conduct the required annual fuel quality test for its diesel generator, as confirmed by a review of generator testing records and staff interviews. This lapse affected all residents and both smoke compartments, with staff noting that the generator's fuel reserves needed contaminant filtering before testing could occur.
Surveyors found that an exit pathway outside a resident room was obstructed by maintenance equipment, including a wheelbarrow, lawn mower, and trash bin, reducing the available exit space to about 12 inches. Staff indicated the items were likely placed there by Landscaping Staff, impacting a significant portion of the facility.
A corridor door to a resident room was found with broken latching hardware, preventing it from closing and latching properly. This deficiency affected a significant portion of the facility's residents and one smoke compartment, as confirmed by staff and direct observation.
A power strip was found suspended under a desk at the Nurse Station, powering computer and printer components, in violation of electrical safety codes. Staff were unaware of the improper installation, which affected a significant portion of the facility.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, as required by policy. Review of nursing schedules showed that RNs were only scheduled on weekdays, with no weekend RN coverage for several months. The DON confirmed knowledge of the requirement, while the Administrator misunderstood the staffing standard. This deficiency had the potential to affect all residents.
The facility did not include RN hours on daily staffing sheets, despite having RN coverage on weekdays and a policy requiring such documentation. The Staffing Coordinator confirmed RN hours were not recorded, and both the DON and Administrator expected accurate postings reflecting all staff who worked.
The facility did not submit the required PBJ staffing data to CMS for one quarter, as mandated by policy and federal regulation. This occurred after the Assistant Administrator, previously responsible for the submission, left the position, and no other staff member was assigned or trained to complete the task, resulting in the missed submission.
The facility failed to ensure accurate documentation for three residents during multidisciplinary care conferences. The ADON/MDS nurse signed for the SSD, resulting in falsified records. Interviews revealed staff awareness of the issue but fear of retaliation. The DON emphasized the importance of accurate documentation, noting that each department should complete only their portion of the MCC.
A resident with severe cognitive impairment was left unsupervised outside for about an hour in 92-degree weather, resulting in elevated body temperature and heart rate. The activities assistant responsible for monitoring the resident failed to do so, despite facility policies requiring supervision during outdoor activities.
A facility failed to maintain a comfortable environment for a resident when the room temperature reached 84 degrees Fahrenheit, exceeding the acceptable range of 71-81 degrees. The resident, who was cognitively intact and had multiple medical conditions, expressed discomfort and preferred a fix to the AC unit. Staff confirmed the facility felt hot due to rising outside temperatures, and there were complaints from residents.
Failure to Schedule Ordered Urology Referral
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to prevent urinary tract infections for one sampled resident with a history of frequent UTIs. The resident was admitted with a diagnosis of UTI and had a BIMS score of 12, indicating moderate cognitive impairment. During interview, the resident stated she had experienced multiple UTIs during her stay and that her physician had referred her to a urologist for evaluation more than six months earlier, but the appointment had not been scheduled. She also stated she was concerned about the frequent UTIs and the lack of attention to the referral. Record review and staff interviews showed the physician order for a urologist evaluation and treatment was entered on 6/2/25, but there was no indication in the EMR that the resident was ever seen by a urologist before June 2026. Staff stated the process was for nursing to document the referral in the EMR and notify DON and social services, and that social services was responsible for scheduling and ensuring completion of specialty appointments. The SS, RN, and DON all stated the urology referral should have been scheduled and completed at the time it was ordered, and the DON stated there was no indication the referral had been completed.
Abuse, Neglect, and Unmonitored Activities
Penalty
Summary
The facility failed to ensure residents were free from verbal, mental, and physical abuse and neglect involving CNA 2 and CNA 3. A maintenance staff member reported observing CNA 2 and CNA 3 laughing and mocking a resident, and later a staff member reported CNA 2 mocking the same resident by repeating phrases the resident frequently said, getting close to the resident’s face, and making the resident more irritated. The resident involved had anoxic brain damage, unspecified dementia, and a BIMS score of 11, indicating moderate cognitive impairment. The DON stated the concern was first brought to her attention by email, but CNA 2 and CNA 3 remained on the schedule and continued working with residents for days before being removed from direct care. The investigation also identified neglect and physical abuse involving other residents. One resident reported that CNA 2 and CNA 3 changed his brief together, spoke Spanish that he could not understand, and did not clean him after removing a soiled brief, instead applying a new brief without wiping. That resident stated the issue had been ongoing and caused grief and discomfort. Another resident with failure to thrive, type 2 diabetes, mood disorder, major depressive disorder, and muscle weakness reported that CNA 3 and CNA 2 did not clean him when changing briefs and only changed the brief, particularly failing to provide perineal care after urination. The facility also identified an incident in which CNA 3 struck a resident in the face with a chuck pad while assisting with cleanup after a bowel movement. A staff witness reported that CNA 3 called the resident disgusting and ugly and slapped the resident across the face with the chuck pad. The resident involved had failure to thrive, type 2 diabetes, bell’s palsy, and paraplegia. The DON stated the facility did not complete required reporting or social services follow-up for the additional residents identified during the investigation, and no documentation was found showing IDT review or care plan evaluation for those residents. In addition, residents and staff reported a pattern of delayed or absent responses to call lights and poor care from CNA 2 and CNA 3. The facility’s investigation also identified that residents were left unmonitored during activities in the dining room. During one activity session, two residents became involved in a physical altercation when one resident hit the other on the face and arm, and multiple staff stated no staff member was present in the dining room at the time. The DON, DSD, AD, AA, and other staff stated the facility process was for residents to be monitored during activities, but the dining room was unmonitored because activity staff were assigned other duties.
Failure to Assess and Document an Unwitnessed Fall With Subsequent Knee Fracture
Penalty
Summary
The facility failed to identify, assess, investigate, and document an unwitnessed fall reported by a resident who later developed a right knee fracture. The resident had a history that included major depressive disorder, hypertension, hyperlipidemia, chronic back pain, hematuria, hypothyroidism, and type 2 diabetes mellitus. According to the resident’s account, she slipped in urine in the bathroom while attempting to stand from her wheelchair, fell to the floor, and afterward had right knee pain and difficulty ambulating. Facility staff later acknowledged that the resident had been interviewed about a fall by nursing staff, but the fall was not documented in the medical record. After the resident complained of right knee pain, nursing staff notified the physician and obtained an x-ray. The x-ray showed a fracture, and staff forwarded the results to the physician. The record and interviews showed that the resident remained at the facility for several days after the fracture was identified, while pain continued and the resident’s mobility declined. Multiple staff interviews described the resident as bed bound or largely unable to get up after the injury, with increased pain and reduced function compared with her prior ability to transfer herself and go to the bathroom or smoke. The medical record lacked timely physician documentation of assessment and plan for the fracture, and staff could not find documentation that physician recommendations such as a knee immobilizer, ice, and elevation were implemented or care planned at the time they were reportedly communicated. The comprehensive care plan was not updated to reflect the unwitnessed fall, the confirmed fracture, the increased fall risk, or the change in condition. Facility staff and leadership also stated they could not find documentation of a post-fall assessment, neurological checks, or other required unwitnessed-fall interventions in the record.
Incomplete Neuro Checks and IDT Documentation After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and to follow its own policies on falls, neuro checks, and documentation for two residents after unwitnessed falls. For the first resident, who had diagnoses including Type 2 diabetes mellitus, osteomyelitis of the right ankle and foot, COPD, and chronic heart failure, the facility’s records showed a moderate cognitive impairment with a BIMS score of 12 out of 15. On the date of the unwitnessed fall, progress notes documented that the resident was found sitting on the floor next to a wheelchair in the dining room after standing to get coffee, sliding to the floor, and landing on the bottom before falling sideways and hitting the right shoulder and head. An SBAR form documented that the primary care clinician was notified and recommended sending the resident to the ER for a head and right shoulder scan. During review of this resident’s Neuro Checklist, which outlined required neuro check intervals (every 30 minutes x2, every 1 hour x3, every 2 hours x24 hours, every 4 hours x5, and every 8 hours for 24 hours), surveyors found that the initial vital signs, level of consciousness, pupil assessments, hand grips, and nurse initials were not completed for two subsequent days. The DON confirmed that the LVN assigned to the resident on those days should have completed the neuro checks to indicate that the resident’s neurological status was assessed. The DON stated that a delay in recognizing early neurological changes could delay the management of a serious neurological problem which could lead to serious negative outcomes such as permanent impaired cognition, speech, function, and mobility. The DON also stated that medical records should be complete and accurate to reflect the care provided. For the second resident, who had diagnoses of Alzheimer’s disease and dementia and a BIMS score of 2 out of 15 indicating severe cognitive impairment, an SBAR documented that the primary care clinician was notified after an unwitnessed fall and that neuro checks were implemented, the resident was to be monitored for delayed injuries, and a one-time CT of the head was ordered. Progress notes for that date indicated that the resident had an unwitnessed fall in the bathroom after walking there and losing balance, with a small abrasion noted on the left big toe and an order placed for a CT of the head. However, review of the IDT Post Incident Meeting form for the following day showed that only the date and time of the IDT meeting were completed, and the remainder of the record was left blank. The DON stated that the IDT note should have been completed to indicate that the IDT met to discuss the fall, the cause of the fall, interventions to prevent recurrence, who was notified, and any new orders, and acknowledged that she did not complete the note. The Medical Records Director and Administrator both stated that residents’ medical records are required to be complete and accurate to reflect the care provided, and that partially completed or incomplete documentation indicates the service was not provided. The facility’s policies and procedures titled “Falls - Clinical Protocol” and “Charting and Documentation” require assessment, cause identification, treatment/management, and monitoring and follow-up after falls, as well as documentation of all services provided and any changes in a resident’s medical or mental condition. The incomplete neuro checks for the first resident and the incomplete IDT documentation for the second resident demonstrate that the facility did not adhere to these policies. The DON specifically linked the failure to complete neuro checks to the potential for delayed recognition and management of serious neurological problems, and the Administrator stated that neuro checks were required to ensure the resident received the proper level of care and that the IDT note was required after an incident to ensure the resident’s care plan was appropriately aligned and that the IDT did not miss anything.
Failure to Accurately Document and Perform Wound Care as Ordered
Penalty
Summary
The facility failed to follow its policy and procedure for charting and documentation in accordance with professional standards of practice for one resident. The deficiency occurred when licensed nurses did not change a resident's wound dressing every shift as ordered by the physician for two consecutive days. Despite this, the electronic medical record indicated that the wound treatment was completed during those days. The discrepancy was discovered through observation, interview, and record review, which revealed that the wound dressing was last changed and dated several days prior, contrary to the documentation in the Treatment Administration Record (TAR). The resident involved was admitted with a diagnosis of a cervical spinal cord injury and a stage 4 pressure ulcer on the coccyx. The resident was cognitively intact and reported that the wound dressing had not been changed as ordered, despite repeated requests to nursing staff. Observation confirmed that the wound dressing was not changed for two days, and the dressing was still dated from the last documented change. Interviews with nursing staff and supervisors confirmed that the facility's process required wound dressings to be changed as ordered, initialed, and dated, and that documentation should accurately reflect care provided. Further review of facility policy and professional standards emphasized the importance of accurate, complete, and objective documentation of all treatments and services performed. The facility's own staff acknowledged that the documentation in the TAR was false, as it did not match the actual care provided. The expectation was for nurses to notify supervisors if a treatment could not be completed, and to ensure all services were properly documented in the resident's medical record.
Failure to Document Resident Urine Output per Policy and Professional Standards
Penalty
Summary
The facility failed to follow its own policy and procedure regarding charting and documentation in accordance with professional standards of practice for one of three sampled residents. Certified nursing assistants (CNAs) did not consistently document a resident's urine output every shift on several specified dates. This incomplete documentation was identified during a review of the resident's bladder elimination record, which showed missing entries for multiple days. The resident involved had a medical history including cerebral infarction, kidney stones, muscle weakness, and constipation, and was assessed as having moderate cognitive impairment. The facility's expectation, as stated by both a licensed vocational nurse (LVN) and the director of nursing (DON), was that CNAs document each instance of assistance with urination promptly and accurately, not just at the end of the shift. However, the bladder elimination record was found to be incomplete, with some entries missing for the days in question. The facility's policy required that all services provided to residents, including assistance with elimination, be documented in the medical record to ensure communication among the care team and to monitor residents' conditions. The American Nurses Association's professional standards also emphasize the importance of clear, accurate, and complete documentation. The failure to document as required meant that the care provided could not be verified and did not meet the facility's or professional standards for recordkeeping.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff, or detailed events leading to the deficiency. No additional information about specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Conduct Required Smoke Damper Testing in HVAC System
Penalty
Summary
The facility failed to maintain its HVAC system in accordance with regulatory requirements, specifically by not conducting the required four-year inspection and testing of the fire/smoke dampers. During a document review and interview with staff, it was found that the last smoke damper testing was conducted on 9/28/20, and no subsequent testing had been performed as required. The facility was unable to provide current inspection and testing records for the smoke dampers. Staff indicated that damper testing for the Skilled Nursing Building was assumed to follow the same schedule as the Main Hospital Building, leading to the oversight. This deficiency affected all 43 residents and both smoke compartments in the facility, as the required periodic inspection and testing of fire/smoke dampers had not been completed.
Plan Of Correction
The last smoke damper inspection was completed on September 28, 2020, exceeding the four-year testing requirement. On April 15, 2025, the facility contacted the licensed HVAC inspection company to inspect and test all fire/smoke dampers within Building 02. The inspection and testing are scheduled on May 5th, 2025, by the vendor. The Maintenance Department Staff were educated on the regulatory differences between hospital and SNF buildings to prevent recurrence. A digital calendar reminder and compliance tracker were implemented to ensure timely testing in 2029. The maintenance lead will be responsible for contacting and scheduling the timely inspections with the vendor.
Failure to Perform Annual Fuel Quality Test on Emergency Generator
Penalty
Summary
The facility failed to maintain compliance with requirements for the Emergency Power Supply System (EPSS) as outlined in NFPA 101 and NFPA 110. Specifically, the facility did not conduct the required annual fuel quality test for its 400-kilowatt diesel generator. During a document review and staff interview, it was confirmed that the last fuel quality test was performed over a year prior, and no recent test had been conducted. Staff indicated that the generator's fuel reserves required contaminant filtering before a test could be performed, which contributed to the lapse in testing. This deficiency affected all 43 residents and both smoke compartments within the facility. The failure to perform the annual fuel quality test was identified through a review of generator testing records and direct staff interviews, confirming that the required maintenance and testing protocols were not followed as mandated by regulatory standards.
Plan Of Correction
The facility failed to conduct the annual diesel generator fuel quality test in 2025. On April 15, 2025, the diesel generator fuel testing vendor was contacted, and a service is scheduled for May 2nd, 2025, for the diesel to be sampled and tested by the certified vendor. The testing requirement was added to the facility's emergency preparedness checklist and calendar. The maintenance lead will be responsible for contacting and scheduling the timely inspections with the vendor.
Obstructed Exit Pathway Due to Maintenance Equipment
Penalty
Summary
During a facility tour and staff interview, surveyors observed that the means of egress was not properly maintained. Specifically, the exit pathway on the southwest side of the building, outside Room 214, was obstructed by a wheelbarrow, lawn mower, and trash bin, reducing the exit access to approximately 12 inches. Staff confirmed that the maintenance equipment was likely placed there by the Landscaping Staff. This obstruction affected 24 of 43 residents and one of two smoke compartments.
Plan Of Correction
All residents were identified as having potential to be affected by this deficient practice. This deficient practice could result in a delay of egress in the event of an evacuation. To correct this, all maintenance and landscaping equipment were immediately removed from the exit route. The Maintenance Department lead re-educated all Maintenance, Landscaping, and Facility staff on April 24, 2025, regarding the necessity of always keeping all means of egress clear and unobstructed. Visual inspections of all exit paths will be conducted daily by the Maintenance Department and the DSD. Any obstruction is reported and resolved immediately. A written log of these inspections will be maintained and audited weekly by the Maintenance Department to ensure compliance.
Non-Latching Corridor Door Due to Broken Hardware
Penalty
Summary
A deficiency was identified when the corridor door to Room 228 was observed to not latch properly during a facility tour. The door had broken latching hardware, which prevented it from fully closing and securing as required. This issue was directly observed by surveyors at 10:17 a.m., and staff confirmed that the malfunctioning hardware was the cause of the problem. This deficiency affected 24 of 43 residents and one of two smoke compartments, as the non-latching door could allow the passage of smoke between compartments. The report specifically notes that the door's inability to latch was due to the broken hardware, as confirmed by staff during the survey.
Improper Use and Installation of Power Strip at Nurse Station
Penalty
Summary
A deficiency was identified during a facility tour and staff interview, where a power strip was found suspended under a desk along the south wall of the Nurse Station. The power strip was approximately an inch and a half off the floor and was being used to power computer and printer components. Staff present at the time confirmed the observation and stated they were not aware of the condition of the power strip. This situation was found to be non-compliant with NFPA 101 and NFPA 70 requirements, which specify that electrical equipment, including power strips, must be installed and maintained in a manner that prevents tension from being transmitted to joints or terminals. The improper suspension of the power strip could result in an electrical fire, and this deficiency affected 24 of 43 residents and one of two smoke compartments. No specific resident medical history or condition was mentioned in relation to this deficiency.
Plan Of Correction
On April 15, 2025, a power strip suspended from under the Nurse Station desk was observed. It was immediately removed and was wall-mounted that supports the necessary electrical equipment. Nursing staff were re-educated on the safe and compliant use of power strips in patient care and administrative areas. The maintenance lead/Maintenance staff and the DSD would be responsible for conducting weekly audits of nurse stations and office areas to identify improper electrical setups. K 920
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours each day, as required by both facility policy and regulatory standards. Review of the facility's RN Coverage Policy, last updated on 05/01/2024, confirmed the requirement for daily RN coverage. Examination of nursing schedules from October 2024 through early April 2025 revealed that RN coverage was consistently provided only on weekdays, with no RNs scheduled on weekends across multiple months. Specific dates were identified in each month where no RN was present for the required hours. During interviews, the Director of Nursing acknowledged awareness of the daily RN coverage requirement and confirmed the absence of RN coverage on weekends during the specified period. The Administrator stated a misunderstanding of the requirement, believing that any nurse, not specifically an RN, was sufficient for coverage. This lack of RN presence on weekends had the potential to affect all residents in the facility.
Failure to Document RN Hours on Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure that registered nurse (RN) hours were identified on the daily staff posting, as required by facility policy. Review of the policy indicated that the daily posting should include a breakdown of RN, LVN/LPN, and CNA hours. However, facility nursing schedules and daily posted staffing sheets for the specified timeframe showed that while RN coverage was provided on weekdays, the daily postings did not document RN hours. Interviews with the Staffing Coordinator confirmed that RN hours were not counted or documented on the daily staffing sheets. Both the Director of Nursing and the Administrator stated their expectation that the daily staffing sheets should be accurate and reflect the staff who worked.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit the required Payroll-Based Journal (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS) for one quarter of the 2025 Fiscal Year. According to the facility's policy, staffing and census data must be collected, validated, and submitted to CMS on a quarterly basis, with confirmation of receipt and validation reports reviewed and retained. However, a review of the facility's PBJ Staffing Data Report revealed that the report for the first quarter of fiscal year 2025 was not submitted. Interviews with facility staff indicated that the previous Assistant Administrator, who was responsible for PBJ submissions, left the position in late December 2024. The Staffing Coordinator stated she had not been trained to submit PBJ data but would assume responsibility moving forward. The Director of Nursing was unsure who was currently responsible for the submission, and the Administrator confirmed that there was no evidence the required data had been submitted for the specified quarter. The deficiency resulted from a lack of clarity and follow-through regarding staff responsibilities for PBJ data submission after the departure of the Assistant Administrator.
Falsified Documentation in Multidisciplinary Care Conferences
Penalty
Summary
The facility failed to ensure the accuracy of documentation according to professional standards for three residents. The Assistant Director of Nurses/Minimum Data Set (ADON/MDS) nurse documented and electronically signed for the Social Services Director (SSD) on specific dates in the multidisciplinary care conference (MCC) notes for three residents. This action resulted in falsified documentation, which could have led to delays in care due to the inaccuracy of the records. Resident 1 was admitted with diagnoses including anxiety, dysphagia, and transient ischemic attack, and had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. Resident 2, admitted with muscle wasting, dysphagia, and major depressive disorder, was cognitively intact with a BIMS score of 13. Resident 3, with major depressive disorder, cerebral infarction, and schizoaffective disorder, also had a BIMS score indicating cognitive intactness. Despite these conditions, the SSD was not present during the MCC meetings for these residents, yet documentation falsely indicated their attendance and input. Interviews with staff revealed that the SSD and a Licensed Vocational Nurse (LVN) were aware of the falsified documentation but feared retaliation if they reported it. The ADON/MDS nurse admitted to altering documentation without notifying the respective department members, claiming to assist the interdisciplinary team. The Director of Clinical Operations acknowledged a complaint about false documentation but justified the ADON/MDS's actions as assistance. The Director of Nursing (DON) emphasized the importance of accurate documentation and stated that each department should only complete their portion of the MCC, highlighting the breach in protocol when the SSD's section was completed in their absence.
Resident Neglect Due to Unsupervised Outdoor Exposure
Penalty
Summary
The facility failed to protect a resident from neglect when the resident was left outside unsupervised for approximately one hour in 92-degree Fahrenheit weather. This incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The resident was admitted with diagnoses including abnormalities of gait and mobility, respiratory failure, conversion disorders with seizures, pain, and muscle weakness. On the day of the incident, the resident was taken outside by an activities assistant (AA) but was forgotten and left unattended. The facility's director of nursing (DON) and other staff members confirmed that the AA was responsible for monitoring the resident while outside. The resident was discovered by a housekeeper and subsequently assisted back inside by a certified nursing assistant (CNA). Upon assessment by a licensed vocational nurse (LVN), the resident was found to have an elevated body temperature of 101.1 degrees Fahrenheit and a heart rate of 136 beats per minute, indicating potential heat-related stress. Interviews with facility staff, including the activities director (AD) and the AA, revealed that the AA was aware of the need for resident supervision during outdoor activities, especially in hot weather. The facility's policy and procedure on abuse prevention emphasized the right of residents to be free from neglect and required staff to provide supervision during activities. Despite this, the AA did not inform other staff members that the resident was outside, leading to the neglect incident.
Facility Fails to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable environment for a resident when the room temperature was recorded at 84 degrees Fahrenheit, exceeding the acceptable range of 71-81 degrees. This was observed by the California Department of Public Health (CDPH) using their thermometer, and confirmed by the facility's own thermometer which read 81 degrees. The unit clerk noted that hot air was being transferred into the room through the air conditioner vent, and the resident expressed discomfort with the room's temperature, preferring a fix to the AC unit over temporary measures like a fan or ice pack. The resident involved was admitted with diagnoses including chronic pain syndrome, rheumatoid arthritis, lupus, anxiety, and fibromyalgia, and was cognitively intact with a perfect score on the Brief Interview for Mental Status. Interviews with facility staff, including the administrator, CNA, LVN, and DON, confirmed that the facility felt hot due to rising outside temperatures and that there were complaints from residents. The facility's policy indicated that residents should remain safe and comfortable during utility outages, with specific procedures if the temperature reached 85 degrees for four hours, but the room temperature had already exceeded the comfortable range.
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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 Coalinga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kings Healthcare & Wellness Center Lp | 39.5 mi | ★★★★★ | 12 | 0 |
| Hanford Post Acute | 39.8 mi | ★★★★★ | 17 | 0 |
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