Coastal View Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 28, 2025

  Based on interview and record review, the facility failed to provide a safe environment and care services for 1 of 3 residents (Resident 3) in accordance with the facility's policies and procedures related to falls by failing to: - Provide Resident 3, after three incidents of falls, a post fall re-assessment and revision of care plan after each fall incident - Notify/alerted a physician that Resident 3 was on an anticoagulant (blood thinner) medication that increased the risk of bleeding. These deficient practices placed Resident 3 at an increased risk of complications. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe food handling when: 1. TCS foods (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not consistently and accurately cooled down. 2. Raw poultry was not thawed safely. 3. Food items were unlabeled and/or undated in the refrigerator in the kitchen, and in the refrigerator adjacent to the nursing station that stored resident food brought in from the outside. These failures had the potential to place the residents at risk for developing a foodborne illness. Findings: 1. […]

• No harm, potential for more than minimal, patternF805Dec 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure the pureed lasagna recipe was prepared according to facility policy when the consistency was not smooth and contained lumps. Dietary Supervisor (DS) confirmed there were six residents (Residents 105, 42, 53, 70, 104, and 91) with physician-ordered puree diets who had potential to receive an inappropriate food texture. This failure had the potential to result in choking and aspiration (the inhalation of food or liquid into the lungs) for residents with swallowing difficulties. During a concurrent observation and interview on 12/16/25 starting at 11:15 a.m. with head cook (HC) in the kitchen, HC was observed preparing and arranging lunch meal trays in the hot box. HC stated the meals were ready to be served. […]

• No harm, potential for more than minimal, patternF658Oct 17, 2024

  Based on observation, interview, and record review, the facility failed to obtain a physician order for siderails for one of 21 sampled residents (Resident 25). This failure had the potential for Resident 25 to experience negative outcomes, while receiving care in the facility. Findings: During a review of Resident 24's, Face Sheet (FS), dated 10/15/22, the FS indicated, Resident 25 was a [AGE] year-old, who was admitted to the facility on [DATE], with admitting diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), and chronic kidney disease (kidneys are damaged and can't filter blood properly). […]

• No harm, potential for more than minimal, patternF804Oct 17, 2024

  Based on observation, interview and record review, the facility failed to ensure to provide daily nutritional needs were met for 72 of 92 residents when they failed to follow the recipe card for making meatballs for the meatball sub sandwiches being served to the residents on regular diets. This failure resulted in food with inadequate nutritional value and had the potential to result in weight loss of residents. Findings: On 10/14/24, at 9:05 a.m. during an interview with a facility cook (Cook 1) and the Dietary Supervisor (DS) and a concurrent observation in the kitchen, [NAME] 1 was observed preparing food for lunch. A review of the menu for October 14-20, 2024, revealed a meatball sandwich was to be served for part of the lunch meal on 10/14/24. […]