Coulterville Rehabilitation & Health Care Center has a 1-star overall rating, with 1-star staffing and 2-star health inspection results. It reports 3.11 nurse staffing hours per resident per day versus the 4.1 federal benchmark, $113,818 in fines over the last 24 months, and a recent abuse citation.
Last inspection: April 7, 2026Penalties, last 24 months: $113,818recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.1112.
Staffing detail
Registered nurses
0.41
Licensed practical nurses
0.79
Nurse aides
1.90
Weekend nursing
2.80
Hours per resident per day.
Total staff turnover: 47%
Registered nurse turnover: 33%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Last yrNowTrend
Long-stay residents on antipsychotic medication
8%7.7%No change
Residents with a fall causing major injury
8.8%1.6%Improving
Residents with pressure ulcers (bedsores)
4.6%5.8%Worsening
Residents with a urinary tract infection
0%3.3%Worsening
Residents who lost too much weight
10.5%19%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
2%3.5%Worsening
Residents whose ability to walk got worse
0%2.1%Worsening
Long-stay residents on antianxiety or sleep medication
26.3%23.7%Improving
Short-stay residents newly given an antipsychotic
5.6%3.4%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
10.2%15.9%Worsening
Residents with depressive symptoms
4%45.1%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Last yrNowTrend
Long-stay residents given the seasonal flu vaccine
—97%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—82.1%—
Short-stay residents given the pneumonia vaccine
95.2%84.3%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited April 2026 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited August 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to have a registered nurse on duty enough hours each day and to keep a registered nurse as the full-time director of nursing. Cited July 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 727 — 42 CFR §483.35 — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited July 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The nursing home failed to protect residents from abuse and neglect by others. Cited April 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: E
Recent history
PENALTY
A federal fine of $113,818 was recorded.
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
INSPECTION
Health inspection found 7 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $113,818 in total fines.
Federal fine
Apr 7, 2026
$113,818
Operator & ownership
Ownership
For profit - Corporation
Chain
Part of TUTERA SENIOR LIVING & HEALTH CARE · 26 homes · 2.1 stars avg
Occupancy
69.3 residents on an average day (92% of 75 beds)
Resident voice
Resident council
Medicare history
Certified for 26 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.