Coastal Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 9, 2025

  Based on interview and record review, the facility failed to provide supervision for one of 14 residents (Resident 1) who was at risk for leaving the facility (elopement) when Resident 1 went out of the facility premises without the facility's knowledge on [DATE]. This failure resulted in Resident 1 leaving the facility unattended and Resident 1 being found by a bystander face down and unresponsive at a bus stop. The bystander called 911 (universal emergency number) and EMS (Emergency Medical Services, a system that provides emergency medical care) responded and resuscitated Resident 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. One plastic spatula (a kitchen utensil with a wide, flat blade used for mixing spreading, lifting, and removing food) had burned handle and brownish color; 2. Nine pieces of large sized steel pan trays with a blackish colored substance on all the edges; 3. Several black colored dots were trapped in the bug light trap and was not clean as needed; and 4. Staff did not check the expiration date of the test strip prior to using. These failures had the potential to cause food contamination and illness for 69 out of 70 residents who received food from the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2023

  Based on observation, interview, and document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when: 1. There was a crusty white substance on several areas of the ice machine; and 2. Kitchen staff did not follow manufacturer's instructions when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause foodborne illness (illness caused by contaminated food) for 66 out of 66 residents. Findings: 1. During an observation on 7/26/23 at 7:45 a.m., accompanied by the dietary manager (DM), the facility's ice machine was inspected. There were streaks of a crusty white substance running along the top and down the left side of the ice machine. […]

• No harm, potential for more than minimal, widespreadF925Jul 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure their pest control program was effective when there were several fruit flies (small flying insects that have the potential to contaminate food) in the kitchen, even though the kitchen had recently been treated for fruit flies. The presence of pests in the kitchen had the potential to result in foodborne illness (illness caused by contaminated food) for 66 out of 66 residents. Findings: Review of the facility's pest control summary, dated 7/6/23, indicated 22 live fruit flies were found in the kitchen. […]

• No harm, potential for more than minimal, patternF880Mar 14, 2025

  Based on observation, interview, and record review, the facility failed to implement infection control measures when: 1. Resident 26's nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen [a colorless and odorless gas that people need to breathe] was hanging and expose on the resident side rails; 2. Staff did not perform handwashing/hand hygiene before and after gloving; 3a. Enhanced barrier precautions signage was not posted on the door for one resident; b. One staff member did not disinfect cap of medication bottle appropriately; and 4. The Physical Therapy Assistant (PTA) hanged the foley catheter bag on his cargo pants pocket. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1. […]