Coastal Manor

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded in accordance with professional standards for food service safety. The deficient practice had the potential to affect all 82 residents of the facility who consume food from the kitchen.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to ensure a written notification of transfer to the hospital was given or sent to the resident and the resident representative (RR) for three residents (Resident (R)17, R76, and R82) of 27 sampled residents reviewed. This failed practice had the potential to affect the resident and the RR by not having the information of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff reported allegation of abuse immediately to the Administrator/designee. The facility further failed to ensure the administrative staff reported allegations of abuse to the state survey agency. This deficient practice was observed in 5 of 7 allegations of abuse reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to investigate 5 of 7 allegations of abuse perpetrated by a resident, Resident #2.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect the residents' right to be from physical abuse perpetrated by a resident, Resident #2. On 05/28/2024, Resident #2 hit Resident #11 in the head. On 10/09/2024, Resident #2 scratched Resident #4 under their right eye. On 10/16/2024, Resident #2 grabbed Resident #1 by their neck. These deficient practices affected 3 (Residents #1, #4, and #11) of 11 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) screening was completed on or before admission or after the resident remained in the facility past 30 days for 1 (Resident #2) of 11 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure a proper transfer was provided for one of six residents (Resident #41) reviewed for accidents. Actual harm was identified on 2/21/2023 when Certified Nursing Assistant (CNA)#7 transferred R#41 without assistance, and this resulted in Resident #41 sustaining a left tibia fracture.

Inspectors wrote4. A review of a Face Sheet indicated the facility admitted Resident #62 on 05/30/2019 with a diagnosis of cerebral infarction with hemiplegia affecting the nondominant side. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #62 had severely impaired cognitive skills for daily decision making based on staff assessment. According to the MDS, the resident required extensive assistance of one person for bed mobility and maximum assistance from staff for transfers. The MDS indicated bed rails were not used as a physical restraint. Review of Resident #62's Care Plan, with a revision date of 11/03/2022, revealed there was no documentation related to use of bed rails. Review of Resident #62's Physician's Orders, revealed there was no order for side rails or bed rails. [...]

Inspectors wroteBased on observations, interviews, and review of facility policy titled, Food Handling Guidelines, Cleaning of Food and Nonfood Contact Surfaces, Food Handing Guidelines, Hand Hygiene, and Sanitation Inspection and Checklist, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility failed to thaw chicken properly, use the three compartment sink appropriately while washing a food processor, transfer food to the tray line appropriately, ensure staff put on a hairnet prior to entering the kitchen, ensure staff washed their hands between glove changes, and ensure food was stored properly. This deficient practice had the potential to affect 83 of 84 residents who received meals from the facility kitchen.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy titled Quality Assurance and Performance Improvement Program (QAPI), it was determined that the facility failed to develop and implement an effective plan of action to address the use of bed rails in the facility. In October 2022, the facility identified assessments were not being completed for residents with bedrails/side rails to determine safety and appropriateness; however, the facility failed to develop a plan of action to address the lack of assessment. This deficient practice affected all 84 residents who currently reside in the facility.

Inspectors wrote2. Review of a facility policy titled, Administering Medications, with an effective date of 08/25/2020, specified, Appropriate Infection Prevention procedures will be followed during the administration of medications. A review of Resident #33's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for most activities of daily living and had a feeding tube. The MDS further indicated the resident had active diagnoses that included dementia and malnutrition. During medication administration observation on 03/08/2023 beginning at 8:52 AM, Licensed Practical Nurse (LPN) #13 administered medications to Resident #33 through the resident's percutaneous endoscopic gastrostomy (PEG) tube. LPN #13 used a 60 cubic centimeter (cc) syringe during the medication administration observation. At 9: [...]

Inspectors wroteBased on observations, interviews, record review, and facility document review, it was determined the facility failed to conduct regular inspection of bed frames, mattresses, and bed rails to ensure compatibility and to identify areas of possible entrapment for 53 of 59 occupied beds equipped with bed rails.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy titled Care Plans, it was determined that the facility failed to develop a care plan to describe the need for, and use of, bed rails for four (Residents #17, #43, #61, and #62) of six residents reviewed for comprehensive care plans.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy titled Administering Medications,, it was determined that the facility failed to ensure a medication error rate of less than 5%. There were two medication errors out of 26 opportunities, which resulted in a 7.69% medication error rate. This deficient practice affected 2 (Resident #25 and Resident #50) of 6 residents observed for medication administration.