Coastal Manor

In the surveyor’s words

From the most serious findings on record at Coastal Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 10, 2023

  Based on observations, interviews, and record review, it was determined that the facility failed to ensure a proper transfer was provided for one of six residents (Resident #41) reviewed for accidents. Actual harm was identified on 2/21/2023 when Certified Nursing Assistant (CNA)#7 transferred R#41 without assistance, and this resulted in Resident #41 sustaining a left tibia fracture. Findings included: A review of a Face Sheet indicated the facility admitted Resident #41 with diagnoses that included muscle weakness and hemiplegia affecting the nondominant side following cerebral infarction. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2025

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded in accordance with professional standards for food service safety. The deficient practice had the potential to affect all 82 residents of the facility who consume food from the kitchen. Findings include: Review of the facility's policy titled, Food and Supply Storage, dated 01/25, revealed All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . […]

• No harm, potential for more than minimal, widespreadF700Mar 10, 2023

  Based on observations, interviews, record review, and facility policy review, it was determined that facility staff failed to assess risks associated with bed rail use, failed to complete bed rail assessments on admission and quarterly thereafter, failed to ensure the bed rail assessments were fully completed, and failed to obtain consent from the resident or resident representative prior to installing bed rails for 6 (Residents #43, #61, #17, #62, #41, and #55) of 6 residents reviewed for bed rails. From a sample of four of six hallways, this failure affected 53 of 59 residents whose beds were equipped with bed rails. Findings included: On 03/10/2023 at 1:27 PM, the Director of Nursing (DON) stated the facility did not have any policies related to resident assessment for bed rail use. […]

• No harm, potential for more than minimal, widespreadF812Mar 10, 2023

  Based on observations, interviews, and review of facility policy titled, Food Handling Guidelines, Cleaning of Food and Nonfood Contact Surfaces, Food Handing Guidelines, Hand Hygiene, and Sanitation Inspection and Checklist, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility failed to thaw chicken properly, use the three compartment sink appropriately while washing a food processor, transfer food to the tray line appropriately, ensure staff put on a hairnet prior to entering the kitchen, ensure staff washed their hands between glove changes, and ensure food was stored properly. […]

• No harm, potential for more than minimal, widespreadF867Mar 10, 2023

  Based on observations, interviews, record review, facility document review, and facility policy titled Quality Assurance and Performance Improvement Program (QAPI), it was determined that the facility failed to develop and implement an effective plan of action to address the use of bed rails in the facility. In October 2022, the facility identified assessments were not being completed for residents with bedrails/side rails to determine safety and appropriateness; however, the facility failed to develop a plan of action to address the lack of assessment. This deficient practice affected all 84 residents who currently reside in the facility. […]