Coalinga Regional Medical CTR Dp/Snf

In the surveyor’s words

From the most serious findings on record at Coalinga Regional Medical CTR Dp/Snf, in the surveyor’s own words.

• Actual harm, patternF656Oct 13, 2021

  Based 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. […]

• Actual harm, patternF692Oct 13, 2021

  Based 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. […]

• Actual harm, patternF840Oct 13, 2021

  Based 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. […]

• Actual harm, isolatedF687Oct 13, 2021

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Apr 10, 2025

  Based 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. Findings included: A facility policy titled, RN Coverage Policy, last reviewed by the facility on 05/01/2024, revealed the section titled, A. Minimum RN Coverage, included, 1. An RN will be on duty a minimum of 8 consecutive hours per day, 7 days a week. Facility nursing schedules for the timeframe from 10/01/2024 through 04/07/2025 revealed RN coverage was provided Mondays through Fridays. […]