Coastal Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Coastal Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF656Mar 6, 2023

  Based on observation, interview, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to the use of a mechanical lift and for Pressure Ulcers (PU) for five (5) of 12 care plans reviewed. (Resident #2, Resident # 4, Resident #5, Resident #6, and Resident #7). The facility did not implement the care plan intervention for a two-person transfer during a mechanical lift when the State Agency (SA) observed Certified Nurse Aide (CNA) #1 using a full body mechanical lift with Resident #2 suspended midair in a sling, without two persons. The facility also did not implement care plan interventions for treatments as ordered and assessed for PUs for Resident #4, Resident #5, Resident #6, and Resident #7. […]

• Immediate jeopardy, patternF686Mar 6, 2023

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed and routine and consistent Pressure Ulcer (PU) care, assessments, and documentation related to PUs were completed for four (4) of five (5) residents reviewed for PUs. (Resident # 4, Resident #5, Resident #6, and Resident #7). The facility's failure to provide routine and consistent wound care, wound assessments, and wound documentation put Resident #4, Resident #5, Resident #6, and Resident #7 and all other residents who are at risk for skin breakdown at risk for serious harm, injury, impairment, or death. […]

• Immediate jeopardy, patternF689Mar 6, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that the residents' environment remained free from actual harm for Resident #1 and the likelihood for harm for Resident #2 for two (2) of five (5) sampled residents, as evidenced by the facility's failure to identify an inoperable mechanical bed with an improperly fitting footboard that resulted in a flap laceration to Resident #1's right lateral foot and failure to prevent the likelihood of injury when the State Agency (SA) observed Certified Nurse Aide (CNA) #1 using a full body mechanical lift with Resident #2 suspended mid-air in a sling, without required two (2) person assistance. […]

• Immediate jeopardy, isolatedF684Mar 6, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to promptly assess a resident for bleeding for one (1) of three (3) residents reviewed on anticoagulant medications (blood thinners) for Resident #1, out of a total of 28 residents who receive medications to thin the blood and failed to ensure residents with non-pressure wounds had consistent assessments, treatments, documentation, and Physician's Orders were followed for one (1) of four (4) residents reviewed for other skin conditions. […]

• Actual harm, isolatedF600Nov 26, 2024

  Based on interviews, record reviews, and facility policy reviews, the facility failed to protect the resident's right to be free from neglect when the facility failed to implement measures to prevent a resident from becoming fecally impacted causing a hospitalization that included dis-impaction and intravenous fluids and neglected to communicate the impaction to the physician for one (1) of four (4) residents reviewed. Resident #1 Findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation, revised 11/16/22 revealed It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of… […]