Coast Care Convalescent Center

Inspectors wroteBased on interview and record review, the facility failed to ensure policies and procedures (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) and Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) were implemented for three of three sampled residents (Residents 5, 8, and 41) by failing to:a. Ensure Resident 8's POLST was updated to reflect the resident did not have an AD.b. Ensure Resident 41's AD was in the medical record.c. Ensure Resident 5's Advance Directive Acknowledgement Form (ADAF) was updated to reflect the resident did not have an AD. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized, comprehensive plan of care for three of three sampled residents (Residents 34, 40 and 41). These failures had the potential to result in the residents not receiving individualized care, affecting their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) for one of one facility kitchen, as evidenced by:1. Four boxes of expired donuts were observed in the refrigerator with use by date of 12/16/25.2. One pack of expired sliced ham was observed in the freezer, with sell by date of 11/10/25.3. Two packs of expired roast beef were observed in the freezer, with sell by date of 10/30/25.4. One container of whole egg mayonnaise was observed in the refrigerator with incomplete open date.5. A sliced watermelon was observed in the refrigerator dated 12/18/25.6. Multiple and undated, brown-colored lettuce heads were observed in the refrigerator. These deficient practices had the potential to cause food-borne illnesses to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure policies and procedures (P&P) on Respiratory Syncytial Virus (RSV, a common respiratory virus that infects the nose, throat, respiratory tract, and lungs) were implemented for two of five sampled residents (Residents 5 and 6) by failing to: a. Ensure Resident 5 was administered the RSV vaccination after it was consented for by Resident 5's responsible party on 7/28/2025.b. Ensure the RSV vaccination was offered to Resident 6 nor Resident 6's responsible party. These failures had the potential to result in respiratory infections that could lead to severe illness and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by residents to call for assistance from facility staff) was within reach (an arm's length) for one of one sampled resident (Resident 43). This deficient practice had the potential to result in delayed provision of services, delays in care and Resident 43 not receiving assistance with activities of daily living (ADL- activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was conducted for one of two sampled residents (Resident 34) who smoked. Resident 34 did not have a smoking assessment completed. This deficient practice had the potential to negatively affect Resident 34's safety and plan of care.

Inspectors wroteBased on interview and record review, the facility failed to revise the Comprehensive Care Plan following the discontinuation of an antidepressant medication (treats depression [mood disorder causing persistent sadness and loss of interest affecting daily life]) Remeron 7.5 milligrams (mg- unit of measurement), for one of one sampled resident (Resident 40). This failure had the potential to result in a delay in care and services in response to a change in Resident 40's needs and goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 8), who was immobile (unable to move) and had limited range of motion (ROM - the extent of movement of a joint) received restorative nursing (a program that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) care and the RNA (Restorative Nursing Assistant- an aid who provides restorative and rehabilitation care to residents) documented the services provided five times a week as indicated in the physician's order. This deficient practice had the potential to place Resident 8 at risk for further decline in ROM and further contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to ensure 19 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 14, 15, 17, 18, 19, 20 and 22) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. This deficient practice had the potential for the residents not to have enough space for activities of daily living and hinder staff from providing nursing care to the residents, affecting the overall quality of life of the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop specific and resident-centered care plans (CP) for three of three sampled residents (Residents 1, 2, and 3). These deficient practices had the potential for Residents 1, 2, and 3 to not receive appropriate care, treatment, and/or services related to their needs.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 1) when the licensed nurse did not take Resident 1's heart rate prior to administration of losartan (medication for high blood pressure) as ordered, from 12/13/2025 to 12/22/2025. These violations had the potential to compromise Resident 1's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy regarding advance directive's (AD, a written document that indicates to health care providers (HCP) who should speak on resident's behalf and what medical decisions to make if resident is unable to speak for self) and Physician Orders for Life Sustaining Treatment (POLST, written medical order from a medical doctor (MD) that indicate specific medical treatment the resident would want to receive during a medical emergency or if the resident is unable to speak for self) for three of three sampled residents (Residents 19, 37, and 43) by failing to: a. Ensure an Advance Healthcare Directive Acknowledgement form (AHCD) was filled out correctly and the POLST was signed by Resident 43's legal representative upon admission. b. Complete an AHCD for Resident 19 upon admission. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for posting nurse staffing data for one of two sampled locations (lobby) by failing to: a. Post accurate hours for Certified Nurse Assistants (CNA) on 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024. b. Post nurse staffing information at the beginning of the shift on 10/23/2024 in the lobby, an area readily accessible by everyone. These failures had the potential to result in posting inaccurate nursing hours and nurse staffing information that could affect the quality of care given to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 38 and 43) on psychotherapeutic drugs (any drug capable of affecting mood, emotions, and behavior) were free from unnecessary medication by failing to: a. Identify specific target symptoms for Resident 43 on Seroquel (medication used to treat schizophrenia [a serious mental disorder in which people interpret reality abnormally]) 50 milligrams (mg, unit of measurement) for schizophrenia manifested by hearing voices and responding to internal stimuli and attempted to perform gradual dose reduction (GDR-stepwise tapering of a dose) for the use of Paroxetine HCL (Paxil, medication used to treat depression [persistent low mood or loss of interest]) 30 mg daily for depression. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for one of one sampled ice machine (IM) by failing to: a. Follow the manufacturer's recommendations for interior cleaning and sanitizing of the Manitowoc IM when moderate amounts of black and yellow substances were observed in the internal components of the Manitowoc IM around the sides of the ice dicer and on the water outlet. The contaminated ice was distributed to 40 residents before breakfast on 10/22/2024. b. Ensure the Manitowoc was deeply cleaned weekly and cleaned monthly as indicated by the cleaning log. These failures had the potential to result in residents to develop water borne illnesses from contaminated ice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of one sampled resident (Resident 14). Certified Nursing Assistant 2 (CNA 2) was standing over the resident while assisting with lunch. This failure had the potential to affect Resident 14's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 30) by failing to ensure the resident's call light was within reach and appropriate to the resident's physical ability. This deficient practice had the potential for Resident 30 not to receive necessary care or services and placed the resident at high risk for fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II recommended specialized add-on services that were appropriate to resident's condition were included into Resident 38's assessment, care planning, and transitions of care for one of two sampled residents (Resident 38). This deficient practice placed Resident 38 at risk of not getting the appropriate specialized care needed for the well- being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to create a care plan (CP) for one of one sampled resident (Resident 25) when Resident 25 had a 10% weight loss within three months. This failure had the potential to result in Resident 25 to develop further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a communication board and/or other functional communication system to a non English speaking resident (Resident 24) for one of one sampled resident. This deficient practice placed Resident 24 at risk for miscommunication and delayed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use appropriate alternative interventions prior to the installation of side rails for one of one sampled resident (Resident 13). This failure had the potential for Resident 13 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of one sampled resident (Resident 23). Licensed Vocational Nurse 1 (LVN 1) did not explain the medication and its purpose to Resident 23 during a medication pass, in accordance with the facility's Policy and Procedure (P&P) on Medication and Treatment Administration This failure resulted in Resident 23 being uninformed about the resident's medication and had the potential for medication error.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were secured and stored in the medication cart in Station One for one of one sampled resident (Resident 34). This failure had the potential to result in missing medications or medication diversion (illegal distribution or abuse of medications for purposes not intended by the prescriber) for Resident 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 18 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20 and 22) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. This deficient practice had the potential for the residents not to have enough space for activities of daily living and hinder staff from providing nursing care to the residents, affecting the overall quality of life of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt the use of alternatives to bed rails before its installation, for three of four sampled residents (Residents 11, 33 and 37). These deficient practices placed Residents 11, 33 and 37 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of five sampled residents (Residents 11,17 and 42) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication by failing to: 1. Attempt a Gradual Dose Reduction (GDR- tapering of a dose) of Aripiprazole ([antipsychotic drug] drug use to treat psychosis [severe mental disorders that cause abnormal thinking and perceptions]) 30 milligrams (mg-unit of measurement) for Resident 17. 2. Attempt GDR of Temazepam 15 mg ([sedative-hypnotic drug] a class of drugs used to induce and/or maintain sleep) for Resident 11. 3. Ensure Ativan was ordered to treat a specific condition documented in the clinical record for Resident 42. 4. Ensure Ativan was administered to treat a specific behavior for Resident 42. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall preventive measures were implemented for one of four sampled residents (Resident 37). Resident 37's bed was not positioned at the lowest position. This deficient practice had the potential for injury, accidents or fall to Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure gastrostomy (a tube inserted through the abdomen wall and into the stomach used for feeding or drainage) tube feeding was provided in accordance with the physician's order, for one of one sampled resident (Resident 41). This deficient practice had the potential to result in weight loss for Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to conduct staff competency for three of three facility staff. This deficient practice had the potential to affect resident care.

Inspectors wroteBased on interview and record review the facility failed to conduct and document one of one facility-wide assessment of staffing resources, necessary to care for the residents. This deficient practice had the potential to not meet the staffing needs of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 18 of 21 resident bedrooms met the minimum requirement measurement of 80 square feet (sq. ft.) per resident in multi-bed occupancy resident bedrooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, and 22 measured less than 80 sq. ft. per resident in multi-bed occupancy bedrooms as indicated in the facility's Client Accommodation Analysis (square footage measurement of the residents' rooms), signed and dated by the administrator (ADM) on 11/9/23. This deficient practice had the potential to result in inadequate space needed to provide nursing care to the residents.