555539
04/10/2025
Coalinga Regional Medical Ctr Dp/Snf
1191 Phelps Ave. Coalinga, CA 93210
F 0727
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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. A facility nursing schedule for October 2024 indicated there were no RNs scheduled to work on 10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, and 10/27/2024. A facility nursing schedule for November 2024 indicated there were no RNs scheduled to work on 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, and 11/30/2024. A facility nursing schedule for December 2024 indicated there were no RNs scheduled to work on 12/01/2024, 12/07/2024, 12/08/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024 and 12/29/2024. A facility nursing schedule for January 2025 indicated there were no RN's scheduled to work on 01/01/2025, 01/04/2025, 01/05/2025, 01/11/2025, 01/12/2025, 01/18/2025, 01/19/2025, 01/25/2025 and 01/26/2025. A facility nursing schedule for February 2025 indicated there were no RNs scheduled to work on 02/01/2025, 02/02/2025, 02/08/2025, 02/09/2025, 02/15/2025, 02/16/2025, 02/22/2025, and 02/23/2025. A facility nursing schedule for March 2025 indicated there were no RNs scheduled to work on 03/01/2025, 03/02/2025, 03/08/2025, 03/09/2025, 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, and 03/30/2025. A facility nursing schedule for April 2025 indicated there were no RNs scheduled to work on 04/05/2025 and 04/06/2025.
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555539
04/10/2025
Coalinga Regional Medical Ctr Dp/Snf
1191 Phelps Ave. Coalinga, CA 93210
F 0727
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
During an interview on 04/09/2025 at 9:46 AM, the Director of Nursing (DON) stated she knew the facility was required to have RN coverage at least eight hours every day, and she revealed that from October 2024 to 04/09/2025 they had not had any RN coverage for the weekends. During an interview on 04/09/2025 at 10:28 AM, the Administrator stated he thought the facility only had to have a nurse scheduled, not necessarily an RN, and the facility did not have an RN scheduled for the weekends.
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555539
04/10/2025
Coalinga Regional Medical Ctr Dp/Snf
1191 Phelps Ave. Coalinga, CA 93210
F 0732
Post nurse staffing information every day.
Level of Harm - Minimal harm or potential for actual harm
Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was identified on the daily staff posting. This deficient practice had the potential to affect all residents who resided in the facility.
Residents Affected - Many
Findings included: A facility policy titled, Posting of Daily Hours per Patient Day (DHPPD), last reviewed by the facility on 05/01/2024, revealed, The posting shall include: Breakdown of RN, LVN [licensed vocational nurse]/LPN [licensed practical nurse], and CNA [certified nursing assistant] hours Facility nursing schedules for the timeframe from 10/01/2024 through 04/07/2025 revealed RN coverage was provided Mondays through Fridays. A facility document titled, Daily Census & NHPPD [Nursing Hours per Patient Day] for the timeframe from 10/01/2024 through 04/07/2025 revealed the daily posted staffing sheets did not identify RN coverage as part of their nursing staff. During an interview on 04/09/2025 at 4:05 PM, the Staffing Coordinator stated she did not count (document) any RN hours on the daily staffing sheets. During an interview on 04/10/2025 at 1:52 PM, The Director of Nursing (DON) stated she expected the staff to make sure the daily staffing sheets were accurate. During an interview on 04/10/2025 at 2:18 PM, the Administrator stated he expected the daily staffing sheets to be accurate and show the staff who worked.
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555539
04/10/2025
Coalinga Regional Medical Ctr Dp/Snf
1191 Phelps Ave. Coalinga, CA 93210
F 0851
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Based on interview, facility document review, and facility policy review, the facility failed to electronically submit the Payroll-Based Journal (PBJ) (staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one quarter of the 2025 Fiscal Year for the facility.
Findings included: A facility policy titled, Payroll-Based Journal (PBJ) Reporting Policy, revised 05/01/2024, revealed, [Facility Name] will maintain an accurate and verifiable system for collecting, validating, and submitting staffing and census data to CMS through the PBJ system on a quarterly basis, as required under 42 CFR [Code of Federal Regulations] §[section]483.70(q). The policy revealed the section titled, 5. CMS Submission, included, A confirmation of receipt and validation report will be reviewed and retained. The facility's PBJ Staffing Data Report for quarter one of fiscal year 2025 revealed the facility did not submit the PBJ report for the first quarter (October 1 - December 31) of fiscal year 2025. During an interview on 04/10/2025 at 12:40 PM, the Staffing Coordinator stated that the previous Assistant Administrator was responsible for the PBJ submission. The Staffing Coordinator stated she would be trained to do the PBJ submission now because she was responsible for staffing and the hours per patient day (HPPD) reporting. During an interview on 04/10/2025 at 2:06 PM, the Director of Nursing (DON) stated the Assistant Administrator left the position in late December 2024. The DON stated that when the Assistant Administrator was at the facility, he had been responsible for submitting the PBJ data. The DON stated she was not sure who submitted the PBJ data now. The DON stated she expected the PBJ data to be submitted in a timely manner. During an interview on 04/10/2025 at 2:31 PM, the Administrator stated he was not able to provide evidence that the first quarter PBJ data was submitted. The Administrator stated it was his expectation that facility staff follow all protocol, policy, and CMS regulations for PBJ data to be submitted timely, and the facility staff should have been doing that.
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