Coastal Health and Rehabilitation Center

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to revise care plans to reflect resident falls and interventions implemented to prevent recurrence for two (2) of three (3) residents reviewed for falls. Resident #1 and Resident #2.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to analyze falls and implement interventions to reduce the risk for recurrence for two (2) of three (3) residents reviewed for falls. Resident #1 and Resident #2.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to store, label, and maintain food in a sanitary manner to prevent contamination and ensure resident safety for one (1) of (1) kitchen observations. Findings Include:Record review of the facility's Food Receiving and Storage, revised July 2014 revealed, Food shall be received and stored in a manner that complies with safe food handling practices.7. Such foods will be rotated using a first in-first out system. On August 4, 2025, at 10:15 AM, during an observation of the kitchen and an interview with the Dietary Manager, the State Agency (SA) observed molded Italian sausages stored inside a box in the walk-in cooler. An open, undated container of garlic parmesan wing sauce was also found in the cooler. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Resident Council grievances were addressed for multiple complaints voiced over several months, including concerns with pest control, linen shortages, and food quality, for multiple residents who participated in the council meetings for three (3) of (3) meeting minutes reviewed.

Inspectors wroteBased on interviews, record reviews, and the facility policy review the facility failed to notify a resident's representative in writing of the reason for the transfer/discharge to the hospital in a language they understand and notify the resident and/or resident's representative of the facility policy for bed hold, including reserve bed payment at the time of transfer for one (1) of two (2) residents reviewed for hospitalization. Resident #128Findings include:A review of the facility's policy Transfer/Discharge Notification & Right to Appeal with revision date of 10/24/2022 revealed . Notice Before Transfer: . the center must: [...]

Inspectors wroteBased on observations, interviews, record reviews, and the facility policy review, the facility failed to refer and follow through with the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for one (1) of 27 sampled residents. Resident #8Findings include:A record review of facility policy Preadmission Screening and Resident Review (PASRR) with revised date of 11/08/21 revealed . The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents received appropriate pre-admission screening according to Federal/State guidelines . Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted . 4. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to implement care plan interventions related to keeping skin clean and dry and providing prompt care after each incontinent episode for one (1) of 27 care plans reviewed, Resident #31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate incontinence care for a resident dependent upon staff for activities of daily living (ADL) to maintain the resident's comfort for one (1) of seven (7) residents reviewed for ADL care, Resident #31.

Inspectors wroteThe facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place on November 15, 2023. The deficiencies were in the areas of unresolved grievances, transfers/discharges, Preadmission Screening and Resident Review (PASSR), Care Plans, Activities of Daily Living (ADLs) and Kitchen. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective Quality Assurance Performance Improvement (QAPI) Committee. This was for six (6) recited deficiency originally cited November 15, 2023, on an annual recertification survey out of (17) deficiencies currently cited. [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to honor a resident's documented meal preferences for one (1) of 27 sampled residents (Resident #84). Specifically, the facility failed to provide meals in accordance with Resident #84's documented food preferences and dietary restrictions. Findings Include: Record review of the facility policy Resident Rights revealed .The resident has a right to a dignified existence, self-determination .33. The resident has a right to reasonable accommodation of individual needs and preferences .A review of the facility's Resident Food Preferences policy, revised July 2017, revealed Policy Statement- Individual food preferences will be assess upon admission and communicated to the interdisciplinary team.3. Nursing staff will document the resident's food and eating preferences. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure a safe, clean, and homelike environment for residents on four (4) of (4) days of the survey, as evidenced by limited pest control access to resident rooms, and a lack of clean bath towels available for resident care.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review the facility failed to ensure a resident was free from physical restraints without first completing an assessment, documentation of a medical symptom, physician orders, or monitoring, as evidenced by the resident was placed in a reclined Geri-chair, which restricted his freedom of movement for one (1) of 27 sampled residents. (Resident #114)

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan to address the resident's visual impairment needs after his glasses were broken for one (1) of (27) care plans reviewed, Resident #86.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to ensure services were provided in accordance with professional standards of practice as evidenced by a nurse who did not enter a Physician's Order for a resident transfer/discharge for one (1) of (27) sampled residents (Resident #93).

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure residents had access to independent leisure activities during all hours, including evenings and weekends, when activity staff were not present, as evidenced by activity carts not being available for residents, for one (1) of four (4) days of survey.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure the resident received proper treatment and assistive devices to maintain vision for one (1) of two (2) residents reviewed for Vision/Hearing. (Resident #86)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that new physician orders were entered into the electronic medical record and administered upon a resident's return from the hospital, which resulted in Resident #110 not receiving an ordered anticoagulant medication (Xarelto) for (14) consecutive days after discharge from the hospital for one (1) of six (6) residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure meals were prepared and served to be visually appealing and palatable, as evidenced by, buns were served saturated with beet or coleslaw juice, vegetables were not served separately from bread items causing texture changes, and residents received watery and overly salty processed turkey for (14) of (14) residents reviewed for food quality. Resident #23, Resident #31, Resident #41, Resident #44, Resident #45, Resident #62, Resident #66, Resident #71, Resident #84, Resident #87, Resident #94, Resident #104, Resident #106 and Resident #110. Findings Include:Review of the facility policy titled, Quality and Palatability undated, revealed, .Food will be prepared by methods that conserve nutritive value, flavor and appearance. [...]

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to maintain an effective pest control program to prevent and control insects when pest control services were limited to common areas, resident rooms with reported pest activity were not routinely treated, and gnat infestations were not addressed with appropriate treatment to prevent or eradicate pest for (13) of (14) residents interviewed during the resident council meeting. Residents #23, #31, #41, #44, #62, #66, #71, #84, #87, #94, #104, #106, #110.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to protect the resident's right to be free from neglect when the facility failed to implement measures to prevent a resident from becoming fecally impacted causing a hospitalization that included dis-impaction and intravenous fluids and neglected to communicate the impaction to the physician for one (1) of four (4) residents reviewed.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to ensure the comprehensive care plan was implemented for one (1) of four (4) residents reviewed.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to ensure a resident received care and services to prevent an impaction causing a hospitalization and a physical decline and failed to communicate the impaction to the physician for one (1) of four (4) residents reviewed.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to wound care for three (3) of four (4) sampled residents. Resident #1, Resident #3, and Resident #4. The failure to implement care plan interventions resulted in Resident #1 acquiring a wound infection with hospitalization. Resident #1, Resident #3, and Resident #4 Findings Include: A review of the facility's policy titled Plans of Care, with a revision date of 09/25/2017, revealed: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Resident #1: [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents received consistent pressure ulcer (PU) care and treatment, for three (3) of three (3) residents reviewed for wounds, Resident #1, Resident #3, and Resident #4, and resulted in Resident #1 acquiring a wound infection with hospitalization. Findings Include: A review of the facility's policy titled Skin and Wound, revised 01/24/2021, revealed, .To provide a system for identifying risk and implementing resident-centered interventions to promote skin health, prevention, and healing of pressure injuries .Skin Impairment Identification: 1. Document presence of skin impairment(s)/new skin impairment(s) when observed . Resident #1: A record review of the Order Summary Report revealed Resident #1 had a physician's order, dated 07/03/24 for wound care to the sacrum daily. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for a resident with an unhealed pressure ulcer for one (1) of three (3) residents sampled residents. (Resident #1) Findings Include: A review of the facility's policy titled MDS, revised 9/25/2017, revealed: .The center conducts initial and periodic standardized comprehensive and reproducible assessments no less than every three months for each resident .using the federal and/or state-required RAI (Resident Assessment Instrument) Each person completing a section or portion of a section of the MDS signs .indicating accuracy . A record review of the admission Record revealed that the facility admitted Resident #1 on 09/07/24 with diagnoses including Osteomyelitis. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow a Physician's Order to obtain a urinalysis and to administer an antibiotic medication promptly for one (1) of four (4) sampled residents observed. Resident #2. Findings Include: A review of the facility's policy titled Physician Orders, revised on 03/03/2021, revealed: .Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. A review of the facility's policy titled Laboratory Diagnostic and X-Ray, revised on 06/21/2021, revealed: .Policy: [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop and/or implement comprehensive care plans regarding incontinent care, Activities of Daily Living (ADLs), and pain for four (4) of 27 sampled residents. Resident #1, Resident #46, Resident #109, and Resident #127

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to administer pain medication as ordered for one (1) of 27 sampled residents. (Resident #127)

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to provide a safe and clean dietary department as evidenced by a dirty ice machine, out of date/expired food and unlabeled/undated foods in the refrigerators and dry storage area for one (1) of two (2) kitchen tours during the survey.

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to honor residents' rights or choices by not completing wound care in time for the resident to enjoy the activities of his choice for one (1) of two (2) residents sampled for choices. (Resident #32)

Inspectors wroteBased on staff and resident interview, record review and facility policy review, the facility failed to promptly resolve grievances regarding food complaints and inform residents of the progress towards a resolution for four (4) of seven (7) residents reviewed regarding grievances. Resident #22, Resident #32, Resident #64, and Resident #84 Findings Include: Review of the facility policy titled, Complaint/Grievance, revised 10/24/22, revealed, Policy: The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution .The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner .Procedure .4. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed notify the Resident and/or Resident Representative in writing, in a language they could understand, of hospital transfers for two (2) of two (2) sampled residents reviewed for hospitalization. Residents #75 and #87 Findings Include: Review of the facility's policy titled, Transfer/Discharge Notification & Right to Appeal, revised 10/24/22, revealed, Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements . Notice Before Transfer: Before a center transfers or discharges a resident the center must: Notify the resident and resident representative(s) of the transfer or discharge and the reason for the moving in writing (in a language and manner they understand). [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide the Resident or the Resident Representative (RR), written notification of the bed hold policy at the time of transfer for two (2) of two (2) sampled residents reviewed for hospitalization. Residents #75 and #87 Findings Include: Review of the facility's, Bed hold Policy, revised 11/1/2017, revealed, Policy: Resident or Resident Representative will be notified on admission, and at the time of transfer (to the hospital or therapeutic leave) of the bed hold policies, according to federal and our state requirements . Procedure: . 2. At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed hold. Requirement at time of transfer is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. 3. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to accurately complete a Pre-admission Screening (PAS) by not identifying a mental disorder resulting in no Level II referral for evaluation for (1) of seven (7) residents reviewed for Preadmission Screening and Resident Review (PASRR).

Inspectors wroteBased on observation, staff and resident interviews, facility policy review, and record review, the facility failed to provide activities of daily living (ADLs) related to nail care and bathing/ showers for two (2) of 136 residents observed during the initial tour.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide incontinent care in a manner to prevent infection for one (1) of four (4) incontinence care observations. (Resident # 109)

Inspectors wroteBased on record review and staff interview, the facility failed to provide Registered Nurse (RN) coverage on 4/16/23 for at least 8 hours in a 24-hour period for one (1) of 25 staffing days reviewed. Findings Include: Record review of a typed statement on facility letterhead, signed by the facility's Administrator, revealed the facility did not have a policy regarding RN coverage. Record review of the Staffing Grid, completed by the facility, with dates from 4/1/23 through 6/24/23, indicated the number of RNs for all shifts on 4/16/23 was zero (0). An interview on 11/14/23 at 12:00 PM, with the Administrative Assistant (AA), confirmed that there was no RN on duty on 4/16/23 because the scheduled RN had called in and the facility did not replace the RN. The AA stated she was aware of the requirement to have an RN in the facility for at least eight (8) hours. [...]

Inspectors wroteBased on observations, interviews, record reviews, and policy review the facility failed to prevent the possible spread of infections for one (1) of six (6) incontinence care observations, one (1) of four (4) pressure ulcer observations, and two (2) of three (3) residents oxygen therapy observations. (Resident #21, Resident #65, Resident #20, Resident #55). Resident #55 Findings Include: A record review of the Minimum Data Set (MDS) with an Assessment Reference Date ( ARD) dated 2/25/21 section G revealed Resident #55 requires extensive assistance with Activities of Daily Living (ADL). A record review of the admission Record revealed diagnoses of Contracture Right Hip and Abnormal Posture. A record review of the Physician orders revealed wound care to right great toe and 3rd digit as follows: Clean with normal saline (NS) pat dry AG to nail bed and cuticle. [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review the facility failed to provide the residents who were unable to carry out Activities of Daily Living (ADL's) the necessary services to maintain good personal hygiene for four (4) of 103 residents observed. (Resident #17, Resident #101, Resident #16, and Resident #55). Resident #17 Findings Include: Review of the facility's Abuse, Neglect and Exploitation Policy, dated 11/2019, revealed: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of residential property. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility nursing service procedure review the facility failed to provide podiatry services for three (3) of 23 residents. (Resident #26, Resident #35, and Resident #103).

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to distribute meals in a safe manner for one (1) of 23 residents. (Resident #26) The facility's, Principles of Safe Food Handling policy, dated 11/2017, revealed . 4.) Chill. Bacteria spread fastest at temperatures between 41 F and 135 F, so chilling food properly is one of the most effective ways to reduce food-borne illness . Observations on 4/22/21 at 7:30 AM, revealed meal trays being delivered to the 100 hall on a tall, open metal rack. All trays except Resident #26 were delivered to the rooms. The tray for Resident #26 was left on the tall, open metal rack, with food in three (3) individual bowls with plastic lids, no insulating dome was noted covering food on tray with a milk and a mighty shake. Observed Resident #26 lying in bed. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to employ a Licensed/Qualified Social Worker for four (4) days of four (4) days of survey.