Coulterville Rehab & HCC

In the surveyor’s words

From the most serious findings on record at Coulterville Rehab & HCC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 7, 2026

  Based on observation, interview and record review the facility failed to provide supervision to prevent elopement. This failure resulted in R1 leaving the facility without staff knowledge and a family member (V6) observing (R1) in her wheelchair in the parking lot, with active cars coming and going. The family member (V6) brought (R1) back inside the facility. No staff knew how long (R1) was outside, or how far (R1) had gotten or where (R1) had gone.This failure resulted in an Immediate Jeopardy (IJ) which began on 3/21/2026 when R1 was able to get out of the facility unnoticed by staff and found by a family member in the parking lot in her wheelchair. Staff were unaware when R1 got out and or how long she had been outside. […]

• Actual harm, isolatedF689Jul 21, 2023

  Based on interview and record review the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents (R13) reviewed for supervision to prevent falls in a sample of 44. This failure resulted in R13 falling twice in one day and sustaining a right inferior orbital blowout fracture and minimally displaced left nasal bone fracture. Findings include: R13's Admission Record, printed on 7/21/23, documents R13 had history of falling, unspecified dementia, unspecified severity, with agitation, unspecified abnormalities of gait and mobility and abnormal posture. R13's Minimum Data Set (MDS), dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF812Aug 30, 2024

  Based on observation, interview, and record review, the Facility failed to ensure the dish machine had the chemical level required for effective sanitation and failed to store food in accordance with professional standards for food service safety. This has the potential to affect all 70 residents residing in the Facility. Findings include: 1. On 8/27/24 at 12:02 PM, V5, Dietary Aid, removed a tray of dishes from the dish machine after the cleaning cycle was completed and placed the tray next to the machine on the clean side of the machine. V5 then placed a tray of dirty dishes in the machine and began another cleaning cycle. When the wash cycle began, V5 placed a sanitizer test strip in the dish water reservoir on the front of the machine. […]

• No harm, potential for more than minimal, widespreadF727Jul 21, 2023

  Based on interview and record review the facility failed to have a Registered Nurse (RN) in the facility for 8 hours daily. This has the potential to affect all 70 residents living in the facility. Findings include: The Facility Nursing Schedule dated July 4th through July 18 was reviewed, and on July 14, 2023, the facility did not have a Registered Nurse (RN) for eight consecutive hours. On 7/20/23 at 3:30 PM, V2, Director of Nursing stated, that was an oversight, and it has been corrected. On 7/21/23 at 10:25 AM V1 Administrator stated, we use the state regulations for our policy for staffing. The facility's Resident Census and Conditions of Residents Form, CMS 672, dated 7/18/23 documents the facility has a census of 70 residents. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2023

  Based on observation, interview, and record review, the Facility failed to store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 70 residents living in the Facility. Findings include: On 7/18/23 at 12:18 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R65's tray. V6 did not test the temperature of the soup before tray was passed to R65. On 7/18/23 at 12:37 PM, V6, Cook, removed a bowl of tomato soup from the microwave and placed it on R30's tray. V6 did not test the temperature of the soup before the tray was passed to R30. On 7/18/23 at 12:47 PM, V6, Cook, removed a pan of hash brown casserole from the oven and placed it on the steamtable. […]