Coastal Oaks Special Care Center

In the surveyor’s words

From the most serious findings on record at Coastal Oaks Special Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF761Jun 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed in accordance with the facility's policies and procedures when an expired emergency medication kit was found stored in the medication store closet. This failure had the potential to result in reduced effectiveness and increased risk of side effects of the medications. Findings: During a concurrent observation and interview on 06/03/25 at 10:19 a.m. with the Director of Nursing, the facility's emergency drug kit was found stored in the medication storage closet with an expiration date of 6/2/25. […]

• No harm, potential for more than minimal, isolatedF803May 10, 2024

  Based on observation, interview and record review, the facility failed to ensure the menu was followed as planned during lunch tray line (a system of food preparation in which trays move along an assembly line) when 2 residents (Resident 18 and 32) small portion diet were not followed. This failure had the potential not to meet the nutritional needs as planned to maintain normal body weight and acceptable nutritional values of residents. Findings: During a concurrent observation with the Dietary Manager (DM) on 5/06/24 at 11:58 a.m., of the lunch meal service in the kitchen steam table, part of the menu for the day (5/06/24),were cheesy mashed potatoes, carrots,and turkey. […]

• No harm, potential for more than minimal, isolatedF842May 10, 2024

  Based on record review and interview, the facility failed to maintain medical records for three of 3 sampled residents (Resident 46, 38 and 44) and for one unsampled resident (Resident 47) were in accordance with professional standards and practices when: 1). Resident 46, physician ordered supplement intakes were not documented in the medical record. 2). Resident 38, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage ((SNFABN) notice of Medicare coverage ending) signature of resident representative was not legible or identified. 3) . Resident 44, Resident-Facility Arbitration Agreement ((RFAA) opting for a private dispute resolution procedure instead of going to court agreement) signature of resident representative was not legible or identified. 4). […]

• No harm, potential for more than minimal, isolatedF848May 10, 2024

  Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 22, 44, and 46) binding arbitration agreements had clearly stated the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and clearly stated the selection of a venue that is convenient to both facility and resident or resident representative. This failure had the potential to result in psychosocial harm in the event of an arbitration dispute. […]

• No harm, potential for more than minimal, isolatedF908May 10, 2024

  Based on observation, interview, and record review, the facility failed to maintain essential equipment and safe operating condition, when the refrigerator gasket was found to have been torn. This failure resulted in the door not being able to seal appropriately and with potential to effect food temperatures. Findings: During a concurrent observation and interview on 05/08/24 at 02:46 p.m. of the snack shack refrigerator, the low-fat milk in the door was 48 fahrenheit (The standard scale used to measure temperature in the United States) when measured with the facility thermometer and verified by the Dietary Manager (DM) . The DM stated they took measurements to get a new refrigerator ordered. […]