Health inspection·January 26, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few outside of Resident 98's room, CNA 2 stated Resident 98 was not part of her group, and she was busy handing out passing snacks to the residents. CNA 2 continued to go down the hall and passing out snacks. CNA 2 did not inform anyone that Resident 98 needed assistance. During an interview on 1/22/24 at 11:15 a.m. with Resident 98 in his room, Resident 98 stated he pushed the call light because he could not find his urinal and he had to go to the bathroom. Resident 98 stated he was no longer able to get up without assistance. Resident 98 stated he was sitting in his own urine and felt frustrated, embarrassed, and helpless. During an observation on 1/22/24 at 11:16 a.m. in the hall outside of Resident 98's room, CNA 2 and CNA 8 were observed going into Resident 98's room. Resident 98 was heard telling the CNAs he did not want to urinate in his bed or himself, but he could not wait any longer. Resident 98 had been unassisted and sitting in his urine for greater than 21 minutes (from 10:55 a.m. to 11:16 a.m.). During an interview on 1/22/24 at 2:44 p.m. with CNA 2, CNA 2 stated .call lights should be answered within 15 minutes, sooner if the resident needed to go to the bathroom . CNA 2 stated she did not answer Resident 98's call light because Resident 98 was not part of her group, and she was busy passing out snacks to the other residents. CNA 2 stated, there were three CNAs working at the time of the incident. CNA 2 stated one of the CNAs was taking her lunch break and Resident 98's CNA was busy in another room. CNA 2 stated she did go into Resident 98's room, turned off his call light and offered him a snack. CNA 2 stated Resident 98 did inform her that he had urinated on himself and on the bed. CNA 2 stated she did not assist Resident 98 because she had to continue to pass out snacks to the other residents and she did not notify anyone that Resident 98 needed help because she did not want to leave the snack cart unattended. CNA 2 stated, she should have waited until there were three CNAs available before she passed out snacks. CNA 2 stated she should have assisted Resident 98 or sent someone in to help him. During an interview on 1/25/24 at 10:45 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 2 did not follow call light policy and did not meet the expectations of her position. DSD stated it was the expectation of the facility that call lights were answered within fifteen minutes regardless of whose group the Resident was in. DSD stated CNA 2 should not have been passing out snacks while there were only two CNA on the floor. CNA 2 left only one CNA to assist residents which resulted in Resident 98 urinating on himself and having to sit in soiled clothes. DSD stated leaving residents in soiled wet clothes puts them at risk for embarrassment and skin breakdown. During an interview on 1/25/24 at 10:45 a.m. with Director of Nursing (DON), the DON stated the CNA 2 did not follow call light policy resulting in Resident 98 feeling embarrassed and frustrated. DON stated, CNA 2 put other residents in danger when she decided to pass out snacks leaving only one CNA to care for the residents alone. DON stated CNA 2 did not work per expectations of the facility. During review of the facility's policy and procedure (P&P) Quality of Life - Dignity dated 8/2009, indicated .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance . During a review of the facility's policy Answering the Call Light dated 10/2010, indicated .General Guidelines .8. Answer the resident's call as soon as possible .6. If assistance is needed when you (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 2 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 enter the room, summon help by using the call signal . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's job description for Certified Nurses [undated] indicated, . Performs Patient Care Activities Appropriately .B. Answers patient lights and performs services in a timely manner that adds to the physical well-being of the patient . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 3 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: 1. During a review of Resident 6's admission Record (AR), dated 1/25/24, the AR indicated Resident 6 was admitted on [DATE] with diagnoses which included quadriplegia (a form of paralysis [the loss of the ability to move and sometimes to feel anything] that affects all of a person's limbs and body from the neck down), chronic pulmonary embolism (blockage of the pulmonary [lung] arteries that occurs when prior clots in these vessels don't dissolve over time despite treatment), and presence of cardiac pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/18/23, the MDS Section C indicated Resident 6 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 6 was cognitively intact. During an observation on 1/24/24 at 9:22 a.m. outside of Resident 6's room, the door frame entering the room had missing and chipped paint. During a concurrent observation and interview on 1/25/24 at 1:32 p.m., with Resident 6, inside of Resident 6's room, Resident 6 stated the missing paint on the door frame bothered him, this was his home, and the facility had not painted the door frame for months. Resident 6 stated, if he was able, he would have painted the door frame immediately after the paint had peeled off. Resident 6 stated, the ceiling tiles and paint missing from the ceiling area above Resident 147's room had been peeling since the COVID (Infectious disease caused by a virus) divider was removed. Resident 6 stated, It is an eye soar, it feels as if the facility does not care about providing a home like environment. During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . DON stated the missing paint on the door frames, wall, and ceiling tiles, should have been repaired quickly. The DON stated the facility did not follow the policy for providing a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 4 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 home like environment. DON stated this could cause the residents to feel they were not cared for. Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 147's AR, dated 1/24/24, the AR indicated Resident 147 was admitted on [DATE] with diagnoses which included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Residents Affected - Some During a review of Resident 147's (MDS), dated 1/16/24, the MDS Section C indicated Resident 147 had a BIMS of 9 which suggested Resident 147 was moderately impaired. During an observation on 1/24/24 at 9:24 a.m. the ceiling area above Resident 147's room, the ceiling tiles were peeling and missing paint from the wall near the ceiling. During a concurrent observation and interview on 1/25/24 at 2:20 p.m., with Resident 147, in Resident 147's room. Resident 147 stated she had to look at the damaged wall and ceiling every time she left her room. Resident 147 stated she felt as if the facility did not care about fixing the building for the residents. Resident 147 stated she was frustrated by the damaged wall and ceiling. During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the DON, the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . DON stated the missing paint on the door frames, wall, and ceiling tiles, should have been repaired quickly. The DON stated the facility did not follow the policy for providing a home like environment. DON stated this could cause the residents to feel they were not cared for. 3. During a review of Resident 19's AR, dated 1/25/24, the AR indicated Resident 19 was admitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, and osteomyelitis, (an inflammation or swelling of bone tissue that is usually the result of an infection). During a review of Resident 19's MDS, dated 1/25/23, the MDS section C indicated Resident 19 had a BIMS of 15, which suggested Resident 19 was cognitively intact. During a concurrent observation and interview on 1/22/24 at 11:12 a.m. with Resident 19, in Resident 19's room, Resident 19's wall was observed to have a TV bracket, with no TV. Resident 19 stated the TV had been missing for one month. Resident 19 stated her TV broke and it was reported. Resident 19 stated she was still waiting for a TV. Resident 19 stated she was straining her neck trying to watch TV on her roommate's TV. During an interview on 1/24/24 at 11:02 a.m. with the Social Services Director (SSD), the SSD stated she was aware of Resident 19's room missing a TV. The SSD stated Resident 19's TV quit working and they had ordered a new TV, but it did not fit on the old wall mount. The SSD stated new brackets were ordered, but they had not received the brackets. The SSD stated the Assistant Administrator ordered the TV and brackets but had been out on leave. During a review of the Work Order Request Form Maintenance Department (Work Order), dated 12/6/23, the Work Order indicated, .Please install new TV in Resident [19]'s room. TV is in the front office, same TV's, bracket should work . Please order new compatible wall mount . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 5 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the DON, the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . The DON stated the facility did not follow the policy for providing a home like environment. This could cause the residents to feel they were not cared for. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 6 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed professional standards of practice when: Residents Affected - Some 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 (Resident 13) . These failures placed Resident 13 at risk for harm from giving consent without full understanding of the risks versus benefits for the psychoactive medication, vaccinations, side rails and his POLST. 2. One of six sampled Residents (Resident 18) refused medications on multiple occasions and the licensed nurses failed to notify the resident's physician. This failure placed Resident 18's health at risk for not receiving the medication's therapeutic benefits. 3. One of three sampled residents (Resident 14) was given pain medication outside of the physician ordered parameters for administration. This failure placed Resident 14 at risk for his pain being treated inappropriately causing adverse side effects. 4. Licensed nurses administered medication to three of six sampled residents (Residents 18, 26 and 147) without providing privacy. This failure placed Resident 18, 26 and 147's dignity and privacy at risk for being violated. 5. Licensed Vocational Nurse (LVN) 2 left insulin (a medication which controls the amount sugar in the blood) unattended on Resident 18's bedside table. This failure placed Resident 18's health and safety at risk when the medication was left accessible and had the potential for ingestion and contamination of the bottle. 6. LVN 1 left Resident 32's liquid medication unattended at bedside. This failure left Resident 32 at risk for not receiving the therapeutic benefits of the medication. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 7 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. During an observation on 01/22/24 at 10:27 a.m. in Resident's room, Resident 13 was lying in bed with his eyes closed. Resident 13 did not respond when spoken to. During a review of Resident 13's admission Record [AR], undated, the AR indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses included sequelae of cerebral infarction (neurological deficits remaining after a cerebral vascular accident [stroke-blockage in a blood vessel in the brain]), dementia (loss of cognitive functioning (thinking, remembering and reasoning), psychoactive substance abuse (drug dependence affecting a person's brain and behavior) and anxiety disorder (persistent and excessive worry). The AR indicated Resident 13 was his own responsible party. The AR also had contact information for two family members. During a review of Residents 13's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 13's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 13 was unable to participate in the assessment. During a review of Resident 13's psychiatrist's progress note dated 12/11/2023, the note indicated, . h/o [history of] Dementia and stroke . He is a poor historian . He is alert and oriented X[times]1 and has periods of confusion . Assessments . Neurocognitive disorder [decreased mental function and loss of ability to do daily tasks] . During a concurrent interview and record review on 1/26/24 at 8:39 a.m. with Licensed Vocational Nurse 1 (LVN) 1, Resident 13's electronic medical record (EMR) was reviewed. LVN 1 stated Resident 13 was forgetful with confusion and only capable of answering simple questions. LVN 1 reviewed Resident 13's Side Rails Informed Consent and Release, and stated Resident 13 signed the consent on 10/31/22 which she had witnessed. LVN 1 stated she was not sure if Resident 13 understood what he had consented to or the risks versus benefits of the side rails. LVN 1 stated she did not think it was appropriate for him to give consent. The informed consents for sertraline (psychoactive medication used to treat depression and other mental illnesses), influenza (highly contagious respiratory infection) and respiratory syncytial virus (RSV-respiratory virus causing infection of the lungs and respiratory tract) vaccinations were reviewed, LVN 1 stated Resident 13 had signed the informed consents, but she did not think Resident 13 could fully understand the risks versus benefits of the medication and vaccinations. Resident 13's POLST was reviewed, Resident 13 signed the POLST on 7/26/23. LVN 1 stated the POLST was a life sustaining decision and Resident 13 should not have signed the POLST himself because she did not think he could fully comprehend it. LVN 1 stated Resident 13's family or the Interdisciplinary Team (IDT-a group of health professionals working together to help a resident make decisions and meet goals) should him to make the decision. LVN 1 stated, I do not think he can make his own decisions. He should not be his own RP [responsible party]. LVN 1 stated if a resident was incapable to be their own RP the facility would reach out to the next of kin, and if next of kin was unable to, the IDT would assist. During a review of Resident 13's care plan for impaired cognitive function, the care plan indicated, . [Resident 13] has impaired cognitive function or impaired thought processes r/t [related to] Dementia . oriented to name only, follows simple direction . able to make simple decisions . such as what clothes to wear . Interventions . Ask yes/no questions in order to determine [Resident 13's] needs . cue, reorient and supervise as needed . Present just one thought, idea, question or command at a time . LVN 1 stated Resident 13 needed time to process his thoughts and could answer one question at a time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 8 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 1/26/24 at 9:04 a.m. with the Social Services Director (SSD) Resident 13's sertraline informed consent was reviewed. The SSD stated Resident 13 was difficult to understand when speaking. The SSD stated a Resident would need to be alert and oriented to give consent for psychiatric medication. The SSD stated Resident 13 did not fully understand all risks possible from the medication. The SSD reviewed Resident 13's psychiatrists progress note dated 12/11/23 and stated the note indicated Resident 13 was alert times one which meant only to himself. The SSD stated she had never called Resident 13's family because she never had the need to. The SSD stated Resident 13's family should have been contacted regarding the informed consent. During a concurrent interview and record review on 1/26/24 at 9:18 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 13's diagnosis and BIMS were reviewed. The MDSC stated Resident 13 had a diagnosis of dementia and BIMS of 99 which indicated he was unable to participate in the cognitive assessment. The MDSC stated, It is not appropriate for him [Resident 13] to be his own RP. Resident 13's informed consents for RSV and Flu vaccinations, side rails, sertraline and the POLST were reviewed. The MDSC stated Resident 13 would need to understand what he was consenting to, including the potential risks versus benefits for them to be valid. During an interview on 1/26/24 at 11:07 a.m. with the Director of Nursing (DON), the DON stated informed consents were acquired for admission, treatment, psychotropic medication, side rails and restraints. The DON reviewed Resident 13's EMR and stated Resident 13 had a diagnosis of dementia. The DON stated Resident 13 was not capable of giving informed consent on his own. Resident 13's POLST was reviewed, and the DON stated he had signed his POLST himself, but it not valid because of his limited decision making capacity. The DON reviewed the informed consents for side rails, sertraline, flu and RSV vaccines. The DON stated she did not consider those consents valid and would contact the family. The DON stated if a resident was not able to make decisions or give consent the family should be contacted next. The DON stated the next step would be for the IDT to meet and discuss the risks versus benefits and what was in the resident's best interest. The DON stated the facility had not had an IDT meeting to determine if it was appropriate for Resident 13 to be his own RP. The facility's policy and procedure (P&P) titled, Informed Consent, dated 3/2019, was reviewed with the DON. The P&P indicated, . Informed consent is a process of providing information, ensuring shared understanding and making decisions in the context of the Resident's needs . If is important that information is provided in a language and manner that the Resident understands . This requires an assessment of learning and communication barriers . The DON stated the P&P was not followed. During a phone interview on 1/26/24 at 11:37 a.m. with the Family Member (FM) 1, FM 1 stated Resident 13 was not capable of making decisions for himself without assistance. During a review of a professional reference found at https://polst.org/wp-content/uploads/2018/03/2018.03.01-Surrogate-Definition-and-Role-in-Advance-Care-Planning.pdf titled Advance Care Planning: Surrogates, dated 3/1/2018, the reference indicated, . Because the POLST form orders direct a patient's medical treatments, the patient must have sufficient decision-making capacity to give consent, meaning that the patient has the mental capacity to understand his or her condition, the benefits and burdens of the proposed course of treatment . During a review of the facility's admission agreement titled, California Standard admission Agreement for skilled Nursing Facilities and Intermediate Care Facilities, dated 5/2011, the admission agreement indicated on page 10-11, . Representative of patient; devolution of rights . Any rights under this chapter of a patient judicially determined to be incompetent or who is found by his physician to be medically incapable of understanding such information, or who exhibits a communication barrier, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 9 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 shall devolve to such patient's guardian, conservator, next of kin, sponsoring agency . Level of Harm - Minimal harm or potential for actual harm During a review of a professional reference found at Residents Affected - Some https://www.aafp.org/pubs/afp/issues/2018/0701/p40.html#:~:text=Capacity%20is%20the%20basis%20of,they%20can%20 titled, Evaluating Medical Decision-Making Capacity in Practice, dated 2018, the article indicated, .Medical decision-making capacity is the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment . Capacity is the basis of informed consent. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes . 2. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate). During a review of Residents 18's MDS assessment dated [DATE], indicated Resident 18's BIMS scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 18 was unable to participate in the assessment. During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 tested Resident 18's fingerstick blood sugar. LVN 2 stated Resident 18's blood sugar would require insulin 3 units according to the physician's order. Resident 18 had refused the insulin (a medication which controls the amount sugar in the blood) injection. During a concurrent interview and record review on 1/25/24 at 9:10 a.m. with LVN 2, Resident 18's Medication Administration Record (MAR) dated 1/2024, was reviewed. LVN 2 stated when a resident refused medication, a code 2 was entered on the MAR and a progress note was written. LVN 2 stated when a resident refused medication for multiple days the physician would be notified. LVN 2 stated when a resident refused insulin it could cause adverse effects such as going into a coma (deep state of unconsciousness) from high blood sugar. LVN 2 reviewed Resident 18's MAR and stated he refused his insulin on 1/24/24 at 11:00 a.m. which was indicated on the MAR with a 2. LVN 2 reviewed Resident 18's progress notes and was unable to locate a progress note which indicated he had refused his insulin. LVN 2 stated she should have documented the refusal. LVN 2 stated Resident 18 frequently refused his medications. LVN 2 stated the physician should have been notified, but she had not notified him. During a concurrent interview and record review on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), Resident 18's MAR and progress notes were reviewed. The DON stated Resident 18 refused medications on multiple days in January. The MAR dated 1/2024 indicated Resident 18 refused medications with a code 2 as follows: 1/5/24, 1/7/24, 1/18/24- Atorvastatin (for hyperlipidemia-high concentration of fats in the blood), Clopidogrel Bisulfate (for cerebral infarction), Sennosides-Docusate Sodium (for constipation), Xalatan ophthalmic solution (to treat glaucoma [increased pressure in the eye causing loss of sight]) 1/8/24-Allopurinol (for gout [arthritis causing severe pain]), Amlodipine (for hypertension [high (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 10 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blood pressure]), Ascorbic Acid (vitamin C), aspirin, Atenolol (for hypertension), Fish oil (a dietary supplement), Vitamin D3 1/10/24, 1/22/24-Atorvastatin Calcium, Clopidogrel bisulfate (cerebral infarction), Sennosides-Docusate Sodium (constipation) The DON stated her expectations when a resident refused medication was for the nurse to offer it three times, explain the risks versus benefits to the resident and if the resident continues to refuse, notify the physician. The DON stated Resident 18's physician should have been notified since he had multiple medication refusals. The DON stated when Resident 18 refused his insulin on 1/24/24, the nurse should have offered it again and followed up by rechecking the residents blood sugar. The DON stated she was unable to locate a progress note to indicate the nurse had rechecked the blood sugar or notify the physician. During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment, dated May 2013, the P&P indicated, . Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician . Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record . The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal . 3. During a review of Resident 14's admission Record [AR], undated, the AR indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses which included acute subdural hemorrhage (bleeding between the brain and skull), rhabdomyolysis (serious medical condition cause by muscle injury), hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain) and aphasia (disorder which affects ability to communicate). During a review of Residents 14's MDS assessment dated [DATE], indicated Resident 14's BIMS scored 11 out of 15. The BIMS assessment indicated Resident 14 had a moderate cognitive impairment. During an interview on 1/22/24 at 10:24 a.m. with Resident 14, Resident 14 indicated by writing he had shoulder pain, was on pain medication and wanted the medication increased. During a concurrent observation and interview on 1/24/24 at 2:47 p.m. with Resident 14, Resident 14 reported his pain was 10/10 to his left shoulder. Resident 14 was not groaning, grimacing or guarding the shoulder. During an interview on 1/25/24 at 11:07 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 14 rarely complained of pain during care. During a concurrent interview and record review on 1/26/24 at 8:31 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 14's Order Summary Report, dated 1/25/24, was reviewed. The orders indicated, . Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth every 12 hours as needed for severe pain (7-10/10 [pain scale used to measure pain 0-3/10 mild pain, 4-6/10 moderate pain, 7-10/10 severe pain]) related to RHABDOMYOLYSIS . Resident 14's Medication Administration Record [MAR], dated 1/2024 was reviewed. LVN 1 stated the MAR indicated Resident 14 was given hydrocodone-acetaminophen 5-325 mg as follows: 1/11/24 pain level 5/10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 11 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 1/12/24 pain level 0/10 Level of Harm - Minimal harm or potential for actual harm 1/22/24 pain level 6/10 1/23/24 pain level 0/10 Residents Affected - Some LVN 1 stated Resident 14's pain was less than 7/10 and he should not have received hydrocodone-acetaminophen according to the physician's order. LVN 1 stated the physician's order was not followed. During a concurrent interview and record review on 1/26/24 at 11:23 a.m. with the Director of Nursing (DON), Resident 14's MAR and physician order for hydrocodone-acetaminophen were reviewed. The DON stated the nurses administered the medication when the pain was lower than 7/10 and did not follow the physician's order. The DON stated her expectation was for the nurses to follow the physician's order. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner and as prescribed . Medications must be administered in accordance with the orders . 4. During an observation on 1/24/24 at 7:29 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 administered medication to Resident 147 with the privacy curtain and door open. During an observation on 1/24/24 at 7:44 a.m. with LVN 3, LVN 3 administered Resident 26's medication while privacy curtain was not closed and her roommate was in the next bed. During an interview on 1/24/24 at 7:54 a.m. with LVN 3, LVN 3 stated she should have closed Residents 147 and 26's privacy curtains. LVN 3 stated the residents were in the room together and did not have privacy while taking their medications. LVN 3 stated she had forgotten to close the curtains. During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with LVN 2, LVN 2 walked into Resident 18's room and checked the residents blood sugar while the curtain and door were left open. LVN 2 stated she should have closed the curtain to give the resident privacy during the procedure. During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated her expectations for medication pass was for the nurses to provide the residents' privacy. The DON stated the curtains should be closed to respect the residents' dignity. During a review of the facility's document titled, Licensed Practical/Vocational Nurse (LVN) Job Description, the job description indicated, . Using independent and interdependent judgment, the Licensed Vocational/Practical Nurse (LVN/LPN) maintains the delivery of quality care . Protect the privacy of patients . During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, dated 8/2009, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 12 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm 5. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate). Residents Affected - Some During a review of Residents 18's MDS assessment dated [DATE], indicated Resident 18's BIMS scored 99 The BIMS assessment indicated Resident 18 was unable to participate in the assessment. During a concurrent observation and interview on 1/24/24 at 11:01 a.m., with LVN 2, in Resident 18's doorway. LVN 2 gathered supplies to test Resident 18's blood sugar and placed the supplies with his insulin bottle into a plastic cup. LVN 2 took the cup into Resident 18's room and placed it on the bedside table. LVN 2 tested Resident 18's blood sugar, left the bottle of insulin on his bedside table and exited the room. Resident 18's insulin was left unattended and accessible. LVN 2 stated, The insulin was left in the room. I should not have left it there. LVN 2 stated Resident 18 had access to the insulin and could have contaminated it. During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated medication should never be left at a resident's bedside because it was a safety issue. The DON stated her expectation was for the nurses to keep medication in their possession or in line of site. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner, and as prescribed . During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse . No medications are kept on top of the cart . cart must be clearly visible to the personnel administering medications . must be inaccessible to residents or others passing by . 6. During a concurrent observation and interview on 1/22/24 at 9:45 a.m. in Resident 32's room, a plastic cup with a slightly translucent liquid and spoon was sitting on the bedside table. Resident 32 stated the cup had his medication to help him 'go' and rubbed his stomach. Resident 32 stated the nurse poured a powder into the water, mixed it and left it at bedside. During a review of Resident 32's admission Record [AR], undated, the AR indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (condition in which your blood does not have enough oxygen) and chronic obstructive pulmonary disease (COPD- group of diseases that block airflow and make it difficult to breathe). During a review of Residents 32's MDS assessment dated [DATE], indicated Resident 32's BIMS. The BIMS assessment indicated Resident 32 had a moderate cognitive impairment. During a concurrent observation and interview on 1/22/24 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1 at Resident 32's bedside, the plastic cup with the translucent liquid was observed. LVN 1 stated she had given Resident 32's [brand name for polyethylene glycol- a laxative for constipation] this morning and left it at bedside. LVN 1 stated the polyethylene glycol was a medication and should not have been left at bedside. LVN 1 stated she should have watched Resident 32 take the medication to verify he did. LVN 1 stated another resident could have access to the medication when left at bedside. LVN 1 stated if someone took the medication and it was not prescribed to them, they could have abdominal pain and diarrhea. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 13 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated medication should never be left at a resident's bedside. The DON stated her expectation was for the nurses stay with the residents and make sure the medication was taken. The DON stated it was a safety issue to leave the medication at bedside. During a review of a facility document titled, Back to the Basics Medication Administration and Storage, dated 2017, the document indicated, . oral medications . Residents should be observed swallowing all medication . Event ID: Facility ID: 555539 If continuation sheet Page 14 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based 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. Findings: During a concurrent observation and interview on 1/24/24 at 10:12 a.m., with Infection Preventionist (IP professional who make sure healthcare workers and residents are doing all the things they should to prevent infections) at medication cart 1, 24 of 31 residents' medication blister packs were observed with no visible expiration date. The expiration date was covered with orange and green stickers indicating am (morning) and pm (afternoon) shifts. IP stated he could not find an expiration date on medication blister packs. IP stated not being able to see expiration date put the residents at risk to receive expired medications. During a concurrent observation and interview on 1/24/24 at 10:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was unable to find the expiration date on 24 resident medication blister packs. LVN 2 stated the stickers were placed over the expiration dates. LVN 2 stated she placed the stickers on the blister packs and that was her practice. LVN 2 validated she had been administering these medications to residents. LVN 2 stated she was not following the facility's policy for medication administration because she could not check the expiration date prior to administering medication to residents. LVN 2 stated if the residents received expired medications, the resident could have potential side effects or ineffective treatment due to medication no longer having desired efficacy. During a concurrent interview and record review on 1/25/24 at 10:58 a.m. with Director of Nursing (DON), the facility's policy, and procedure (P&P) titled, Administering Mediations dated 12/2012 was reviewed. The P&P indicated, .9. The expiration/beyond use date on the medication label must be checked prior to administering DON stated stickers should not be placed over the expiration date. The DON stated the nurse would not be able to verify if the medication had expired. The DON stated the nurse could give residents expired medications that may have lost its efficacy. During a review of the Federal Drug Administration (FDA)'s article titled Pharmaceutical-quality-resources/expiration Dates dated 10/2022, the Pharmaceutical-quality-resources/expiration Dates indicated . Drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 15 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based 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. This failure had the potential to result in the growth of spore-forming bacteria (highly resistant, dormant [no metabolic activity] structures formed in response to adverse [unfavorable] environmental conditions) or toxin-forming bacteria (organisms which are capable of producing toxins [substances that are poisonous to humans]) on improperly cooled food, resulting in bacterial food born illness (illness caused by ingestion of contaminated food or beverages) for 49 out of 49 residents who consumed food from the kitchen. Findings: During a concurrent observation and interview on 1/23/24 at 9:05 a.m. with [NAME] (CK) 2 in the kitchen, CK 2 was asked about the cool down process for hot foods. CK 2 stated, The cool down process of hot foods was to note the temperature of the food immediately from taking it out of the oven and two hours later check the temperature and after four hours check the temperature again. CK 2 was not able to state the safe temperature reading at the first two hours. During a concurrent interview and record review on 1/23/24 at 9:12 a.m. with the Certified Dietary Manager (CDM), the [Facility] Cool Down Log, dated 1/10/24 was reviewed. The [Facility] Cool Down Log indicated, .Bread pudding temperature at 11:00 a.m. was listed at 189 degrees F. [Fahrenheit], at 1:00 p.m. the temperature reading was at 169 degrees F., at 5:00 p.m. the temperature reading was at 40 degrees F . The CDM stated the bread pudding cool down process was not correctly followed. The CDM stated the cooling temperature should have started at 140 degrees F. During a concurrent interview and record review on 1/24/24 at 1:25 p.m. with the CDM, the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated, . When cooked PHF [ Potentially Hazardous Food] or TCS [Time/Temperature Control for Safety] food will not be served right away it must be cooled as quickly as possible . Cool cooked food from 140 degrees Fahrenheit [F] to 70 degrees F within two hours. Then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours . The CDM stated his expectation was that staff was aware of procedures and followed guidelines. The CDM stated his expectation was that, we served tasty, healthy, and palatable food. During a review of In-service Program Sign-in Sheet, Cooling and Reheating of Hazardous Foods dated 4/25/23, the In-service Program Sign-in Sheet, Cooling and Reheating of Hazardous Foods did not show if the CK 2 had attended the in-service. During a review of professional reference titled, FDA Food Code 2022, section 3-501.14 Cooling, dated 2022, indicated, .Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 16 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures, 21oC [degrees Celsius] - 52oC (70oF [degrees Fahrenheit] - 125oF), is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135ºF to 41°F or 45°F in 6 hours, with cooling from 135ºF to 70°F in 2 hours . The initial 2-hour cool is a critical element of this cooling process . if cooling from 135ºF to 41°F or 45°F is achieved in 6 hours, but the initial cooling to 70ºF took 3 hours, the food safety hazards may not be adequately controlled During a review of professional reference titled, FDA Food Code 2022, section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, dated 2022, indicated, .Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature [Danger Zone] of 5oC to 57oC (41oF to 135oF) too long . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 17 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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: Residents Affected - Some 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. This failure had the potential for growth of pathogenic bacteria and cause food born illness (illness caused by ingestion of contaminated food or beverages) to residents who consumed the improperly reheated food and placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During a concurrent observation and interview on 1/22/24 at 9:36 a.m. with the Certified Dietary Manager (CDM) in the walk-in freezer, a frozen item was observed under the food storage rack. The CDM stated it looked like an unwrapped hamburger patty. The CDM stated there should be no food under the storage rack. The CDM stated the area should be clean. During an interview on 1/23/24 at 11:12 a.m. with the CDM, the CDM stated his expectation was that the kitchen area was clean, and that staff was aware of cleaning in the kitchen. During a review of [facility] Daily Cleaning Schedule (Cleaning Schedule), dated week of 1/22 - 1/28/2024, the Cleaning Schedule did not show staff initials for sweeping the freezer floor on 1/22 for the p.m. (afternoon) shift, and on 1/23 for the a.m. (morning) shift. During a review of the facility's policy and procedure titled, Sanitation Section 8 dated 2023, indicated, . The FNS (Food and Nutrition Services) Director will write the cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task . the kitchen staff is responsible for all the cleaning . During a review of professional reference titled, FDA Food Code 2022, section 4-602.13 Nonfood-Contact Surfaces, dated 2022, indicated, .Non FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 18 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a concurrent observation and interview on 1/23/24 at 9:36 a.m. with the CDM in the staff lounge, the resident nourishment refrigerator was observed with a resident meal tray inside the refrigerator. The CDM stated the meal tray was being held for a resident who left the facility for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment. The CDM stated they would hold the meal tray for the residents in the resident nourishment refrigerator and staff would reheat the meal tray when the residents returned from their appointments. During an interview on 1/23/24 at 10:36 a.m. with Resident 40, Resident 40 stated staff would warm her food if it was cold. During an interview on 1/25/24 at 9:32 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated staff would hold resident's meal tray if the resident was sleeping or if the resident was not there to eat the meal. LVN 3 stated, We would store the resident's meal tray in the resident nourishment refrigerator. LVN 3 stated the Certified Nursing Assistant (CNA) would warm up the resident's meal tray when the resident came back. LVN 3 stated there was no training for reheating resident's meal trays. During an interview on 1/25/24 at 10:38 a.m. with the Director of Staff Development (DSD), the DSD stated staff would hold a resident's meal tray if the resident was not there to eat their food. The DSD stated the CNAs would reheat the resident's meal tray when they returned from their appointments . The DSD stated the CNAs did not have a thermometer to check the food temperature. The DSD stated the CNAs would need to touch the resident's food to be sure it was warm. The DSD stated they had not done an in-service on reheating food. During an interview on 1/25/24 at 10:57 a.m. with the CDM, the CDM stated CNAs would need to reheat food to 165 degrees Fahrenheit (F). The CDM stated residents could get a food born illnesses if the food was undercooked or over-cooked. The CDM stated the resident's mouth could get burned if the reheated food was too hot. The CDM stated he did not feel it was appropriate for CNAs to reheat food. During an interview on 1/25/24 at 11:00 a.m. with the Registered Dietician (RD), the RD stated it was not appropriate for CNAs to reheat residents' meal trays. The RD stated the food could be outside of appropriate temperatures. The RD stated there should be better communication with the kitchen about holding residents' meal trays. The RD stated it was not appropriate for staff to touch the resident's food to see if it was warm. The RD stated staff touching the resident's food with their hands could cause cross-contamination. During an interview on 1/25/24 at 11:33 a.m. with CNA 3, CNA 3 stated she had put residents' food in the resident nourishment refrigerator if the residents were not at the facility during meal service. CNA 3 stated she had reheated meal trays in the microwave. CNA 3 stated to check the temperature she just asked the resident if the temperature was okay. During an interview on 1/26/24 at 1:11 p.m. with Resident 28, with LVN 1 translating, Resident 28 stated when he went to dialysis staff would save his food. Resident 28 stated he did not like it because when he came back from dialysis, the food tasted different. Resident 28 stated the food tasted like it was expired food. Resident 28 stated the CNA would reheat his food. Resident 28 stated when the CNA reheated his food it tasted dry. During a concurrent observation and interview on 1/26/24 at 1:41 p.m. with Resident 42, with LVN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 19 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some translating, Resident 42 was observed eating food from a styrofoam container. Resident 42 stated when he would go to dialysis, the facility saved his meal tray. Resident 42 stated if he did not want what was on the tray, he would buy something else. Resident 42 stated it was the CNA that warmed his food. During a review of the Order Listing Report dated 1/26/24, the Order Listing Report indicated, . dialysis for [Resident 28] on Tuesday, Thursday, and Saturday at 6:15 a.m. During a review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, indicated, .Previously cooked PHF (Potentially Hazardous Foods) or TCS (Time/Temperature Safety) food . should be rapidly reheated to an internal temperature of 165 degrees F within two hours. Internal temperature must then register 165 degrees F for fifteen seconds. Be sure the food reaches a full 165 degrees F when reheating . During a review of professional reference titled, FDA Food Code 2022, section 3-403.11 Reheating for Hot Holding, dated 2022, indicated, . (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC [degree Celsius] (165oF) [degrees Fahrenheit] and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 20 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During the entrance conference interview with the Administrator (ADM) on 1/22/24, at 9:54 a.m., the facility assessment was requested which was part of the list of documents he needed to provide in a timely manner. The Entrance Conference form indicated the ADM was to provide the facility assessment within 4 hours of entrance. During an interview on 1/24/24 at 10:15 a.m. with the ADM, the ADM stated the skilled nursing facility (SNF) was part of the general acute care hospital (GACH) and the facility assessment was part of the campus wide assessment. The ADM would not directly answer if the SNF was assessed separately to address the individual needs of facility residents. During an interview on 1/24/24 at 4:17 p.m. with the ADM, the ADM was unable to locate a SNF facility assessment. During an interview on 1/25/24 at 4:18 p.m. the ADM provided a copy of the facility assessment dated [DATE] which indicated it had been reviewed on 1/31/24. During a concurrent interview and record review on 1/26/24 at 2:00 p.m., with the ADM, the facility assessment was reviewed. The assessment indicated, . Date(s) of Assessment or Updated . January 4, 2024 . Date(s) Assessment Reviewed w/ QAA/QAPI Committee 1/31/24 . The ADM was unable to explain why the reviewed date was in the future. During an interview on 1/26/24 at 3:58 p.m. with the ADM. The ADM stated he was unable to provide evidence of a previous facility assessment and was unsure if the facility assessment had been updated annually according to regulations. The facility was unable to provide a policy and procedure for the facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 21 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based 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. Findings: During a review of facility's Offsite Prep ([undated] -survey information provided by CMS to review prior to surveying facility). The Offsite Prep indicated, the facility did not submit the PBJ report for the fourth quarter of fiscal year 2023. During an interview on 1/25/24 at 10:58 a.m. with Director of Nursing (DON), the DON stated she was not responsible for submitting the PBJ report. The DON stated she was aware the PBJ report was not submitted for the fourth quarter of 2023. The DON stated she was aware that the PBJ report needs to be submitted to CMS quarterly. DON stated the Assistant Administrator (AA), was responsible for sending the report. The DON stated if the AA was unavailable the Administrator (ADM), was responsible for sending the report . The DON stated she was aware of the deficient practice if the PBJ report was not submitted to CMS. During an interview on 1/24/24 at 4:17 p.m.with Administrator (ADM), the ADM stated he was aware the PBJ was not submitted for the fourth quarter, and he was aware. The ADM stated the AA was responsible for sending the PBJ report and the AA had been out of the office for an emergency and he had not been able to speak with him. The ADM stated, when the AA was unavailable the facility hadhad no designated staff member to perform his duties. A review of CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, Version 2.6., dated June 2022, indicated, .(5) Submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely 2) Uploading data directly from an automated payroll or time and attendance system will function very similarly to how MDS data are submitted currently. The data will be required to meet very specific technical specifications in order to be successfully submitted . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 22 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: Residents Affected - Few 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. Findings: 1. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate). During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with LVN 2, LVN 2 walked into Resident 18's room with a lancet (a small blade with a sharp point) and glucometer to test Resident 18's blood glucose. LVN 2 took Resident 18's finger and used the lancet to poke the finger and draw blood. LVN 2 used the glucometer strip in the machine and place the blood on the strip. LVN 2 walked out of the room to the medication cart and opened the top left drawer and placed the glucometer in the drawer, closing it. LVN 2 stated she had forgotten to clean the glucometer prior to placing it in the drawer. LVN 2 stated she should have cleaned the glucometer before placing in the drawer because it was contaminated with germs and blood. During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), The DON stated the nurses were expected to disinfect (to kill germs on surfaces) the glucometer thoroughly prior to putting it into the medication cart. The DON stated it must be cleaned and disinfected for infection control. During an interview on 1/26/24 at 4:14 p.m. with the Infection Preventionist (IP- professional who make sure healthcare workers and residents are doing all the things they should to prevent infections), the IP stated the nurses should clean and disinfect the glucometers after use for infection prevention. The IP stated he had done spot checks for the nurses on glucometer use, but had no documentation to validate LVN 2 had been observed. During a review of the facility's document titled Performing Glucometer Check &Cleaning/Disinfecting Glucometer, undated, the document indicated, . (Glucometers should have been cleaned/disinfected before putting them back to med cart) . Glucometer cleaning and disinfecting must be done in between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 23 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coalinga Regional Medical Ctr Dp/Snf 1191 Phelps Ave. Coalinga, CA 93210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 resident's use . Level of Harm - Minimal harm or potential for actual harm During a review of a professional reference titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 3/2011, from the Centers for Disease Control and Prevention (CDC-), the article indicated, . (CDC) has become increasingly concerned about the risks for transmitting hepatitis B (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring . Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions . Residents Affected - Few During a review of the manufacturer's instructions the facility provided, the instructions indicated, .Cleaning and disinfecting procedures for the meter . the Evencare G3 Meter should be cleaned and disinfected between each patient . 2. During an observation on 1/22/24 at 9:45 a.m. in Resident 32's room, Resident 32 was observed sitting at bedside with oxygen on via nasal cannula (thin flexible tubing that goes into the nose and is used to provide supplemental oxygen). There was extremely long oxygen tubing coiled up on the floor next to him. During a review of Resident 32's admission Record [AR], undated, the AR indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (condition in which your blood does not have enough oxygen) and chronic obstructive pulmonary disease (COPD- group of diseases that block airflow and make it difficult to breathe). During a review of Residents 32's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 32's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment). The BIMS assessment indicated Resident 32 had a moderate cognitive impairment. During a concurrent observation and interview on 1/23/24 at 3:33 p.m. with Resident 32 and Licensed Vocational Nurse (LVN) 1, Resident 32 was observed standing at bedside with the oxygen tubing curled up on the floor at his feet. Resident 32's floor was sticky and LVN 1 stated Resident 32's roommate would spit on the floor frequently. Resident LVN 1 stated Resident 32's tubing was on the soiled floor and could cause an infection control issue and was an accident hazard. During an interview on 1/25/24 at 4:17 p.m. with the Director of Nursing (DON), the DON stated Resident 32's oxygen tubing should not have touched the floor. The DON stated it was an infection control and safety hazard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555539 If continuation sheet Page 24 of 24