Coastal Manor

Inspectors wroteBased on observations and interviews, the facility failed to ensure the dignity of all residents by allowing an uncovered urine filled catheter bag to be seen by passersby for 3 of 3 residents with urinary catheters. (Residents #1, #8 and #9) Findigs: 1. On 12/1/25 at 9:15 a.m. during an initial observation, Resident #1 and #8 both had uncovered foley catheter bags containing urine and visible from the hallway. At 9:30 a.m., both the surveyor and the charge nurse observed the above. At this time, the above was confirmed with the Director of Nursing. 2. On 12/1/25 at 10:13 a.m., observation of Resident #9 lying in a low bed with a foley catheter bag resting on the floor. The catheter bag had dark yellow urine and visible from the hallway. Next to the foley catheter bag was a blue privacy bag hanging. [...]

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for 2 of 2 floors. (first and second floor) for 3 of 4 days of survey.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure medications were administered safely, accurately, and in accordance with provider orders and professional standards of practice for 1 of 3 medication administration observations reviewed. (Resident #14 & #33) On 12/2/25, at approximately 8:15 a.m., during a medication administration observation on the second floor, the surveyor observed the Infection Preventionist (IP) open the top drawer of the medication cart and remove a small plastic bag containing a syringe labeled Omeprazole for Resident #14. When the surveyor asked where the original medication bottle was and when the medication had been prepared, the IP stated he had prepared the Omeprazole syringe prior to starting his medication pass that morning. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure that the resident's environment was free of accident hazards relating to chemicals being properly secured for 3 of 3 observations for 3 of 4 days of survey.

Inspectors wroteBased on observations, record reviews, interviews and facility policy, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care. (Resident #38 and #20)

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure temperature documentation was consistently completed for the medication room refrigerator used to store insulin, vaccines, and other refrigerated medications for 1 of 1 medication room refrigerator reviewed. Review of the facilities Refrigerator Temperature Log Summary (June - December 2025) identified days where required AM and PM temperature checks were not recorded. June 2025Temperatures were not documented on 18 shifts total (10 AM shifts and 8 PM shifts). August 2025Temperatures were not documented on 17 shifts total (9 AM shifts and 8 PM shifts). September 2025Temperatures were not documented on 21 shifts total (9 AM shifts and 12 PM shifts). October 2025Temperatures were not documented on 9 shifts total (4 AM shifts and 5 PM shifts). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 resident reviewed for activities of daily living care. (Resident #32)

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a resident's choice in meal preferences was followed for 2 of 3 sampled residents (resident #1 and #29).

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 4 sampled residents reviewed for new admissions (Resident #38).

Inspectors wroteBased on record review and interview the facility failed to ensure that a residents' care plan was developed within seven days after each comprehensive assessment for 1 of 4 residents reviewed for activities (resident #33).

Inspectors wroteBased on observations, interviews and record review the facility failed to provide residents a whirlpool/shower/shampoo as directed by the resident's shower schedule for 1 of 1 resident reviewed for Activities of Daily Living (ADL's)(Resident #32).

Inspectors wroteBased on care plan reviews, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 1 of 4 residents reviewed for activity participation. (Resident #1).

Inspectors wroteBased on interview and record review the facility failed to follow a physician order relating to diabetes management for 1 of 1 resident reviewed for insulin. (Resident #38)

Inspectors wroteBased on interviews, observation, record review and facility policy review, the facility failed to provide appropriate treatment and services to prevent the risk of complications related to enteral feeding for 1 of 1 resident reviewed for enteral feeding. (Resident #14)Record review of Resident #14's physicians orders dated 10/13/25 required staff to check for Gastric tube (G-Tube) placement and residual prior to administering medication and flush the G tube with 60 cc's of water following medication administration. The physicians' orders also indicated that crushed medications may be administered together via the G-tube. Care plan review for Resident #14 indicated the resident will have no complications related to the feeding tube. [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to assure that adaptive cups were available for 1 of 1 resident as directed by their care plan and physician orders (Resident #29).

Inspectors wroteBased on observations and interview, the facility failed to serve and store food in a sanitary manner on 2 of 4 survey days. (12/1/25 and 12/2/25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and spread of infection relating to hand hygiene during 1 of 3 medication passes observed, linen handling and Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for wound management (Resident #38) and 1 of 4 residents reviewed for indwelling foley catheter (Resident #9).

Inspectors wroteBased on record review, review of the facility's Pneumococcal policy, and interviews the facility failed to implement their Pneumococcal policy for 1 of 5 sampled residents (resident #31).

Inspectors wroteBased on observations and interviews the facility staff failed to provide access to resident call bell device for 3 of 35 residents (#2, #3, and #4).

Inspectors wroteBased on observations, review of 4-week menu cycle, and interviews, the facility failed to follow the printed menu for 3 of 3 days of the survey, and not complying with regulation 483.60(c)(2) that menus be prepared in advance; and 483.60(c)(3) that menus must be followed. This has the potential to effect all 33 of the residents in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 2 of 2 units.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately in the area of Active Diagnosis for 1 of 3 sampled residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (Resident #9).

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan for a resident with a current diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 3 sampled residents reviewed (Resident #9).

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 2 of 3 sampled residents reviewed with a current diagnosis of PTSD (Resident #9, and #31).

Inspectors wroteBased on observations and interviews, the facility failed to serve food that was at an appetizing temperature to residents on 2 of 2 floors.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's physician and/or representative were notified immediately of a significant change in the resident's medical condition and failed to follow its own policy and procedure for Unwitnessed falls and Head injury protocol for 2 of 4 residents reviewed for falls. (#1, #4)

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to adequately assess, monitor and/or complete neurological assessments after unwitnessed falls for 4 of 5 resident reviewed for falls (#1, #3, #4 and #5).

Inspectors wroteBased on interview and record review, the facility failed to review and update the facility assessment at least annually (between 10/2022 and 04/2024) to determine what resources are necessary to care for its residents competently during day-to-day operations.

Inspectors wroteBased on review of the quarterly Quality Performance Improvement Committee meeting attendance sheets and interview, the facility failed to ensure that the Administrator attended 5/5 quarterly meetings.

Inspectors wroteBased on record review, observations and interview, the facility failed to implement a care plan in the area of falls for 1 of 17 sampled residents (#19), and failed to develop a care plan in the area of oxygen/respiratory needs for 1 of 3 residents reviewed for respiratory care (#24)

Inspectors wroteBased on record review and interviews, the facility failed to revise the care plan to reflect the current needs of a resident in the area of respiratory. (#14)

Inspectors wroteBased on observation, record review and interview, the facility failed to provide respiratory care according to physician orders for 2 of 3 residents (#14 and #20) and failed to obtain physician orders for oxygen therapy for 1 of 3 residents (#24) reviewed for respiratory care.

Inspectors wroteBased on observations and interviews, the facility failed to remove spoiled items from the refrigerator located in the kitchen and failed to discard expired dry goods for 1 of 4 days of survey. On [DATE] at 9:00 a.m., during the initial tour of the kitchen with the Cook, the following was observed: 1. The Kitchen refrigerator contained a head of brown wilted lettuce and 3 cucumbers which were shriveled up on the ends. 2. Dry storage contained a stack of pie shells in saran wrap with no expiration date, 1 Package of hot dog rolls with expiration date of [DATE] and 6 packages of English muffins all with expiration date of [DATE]. At this time, the above concerns were confirmed with the Cook.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure the Treatment Administration Record (TAR) was accurately documented for Oxygen (O2) tubing replacement for 2 of 3 residents observed for respiratory care. (#14, #20)

Inspectors wroteBased on record review and interview, the facility failed to ensure its infection prevention and control program (IPCP) included standards, policies and procedures that that were based on its facility assessment and reviewed at least annually.

Inspectors wroteBased on facility policy reviews, interviews, and observations, the facility failed to ensure that Coronovirus (Covid-19) policies and procedures were implemented based on Centers for Medicare and Medicaid Services (CMS) guidance for unvaccinated staff.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 17 sampled residents observed for 2 of 4 days of survey (#19).

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 1 medication rooms and failed to ensure that medications were stored properly by having an unlocked, unattended treatment/medication cart allowing residents and unauthorized persons access to Treatments/medications, on 1 of 3 days of survey.

Inspectors wroteBased on interview, the facility failed to ensure that Quality Assurance meetings were held for 4 of 4 meetings in the last 12 months.

Inspectors wroteBased on interviews, the facility failed to provide residents access to personal funds after business hours during the evenings and on weekends for 1 of 1 resident's reviewed for personal funds with the facility. (#14)

Inspectors wroteBased on interview and record review, the facility failed to review and update the facility assessment at least annually (between 11/2020 and 11/2021) to determine what resources are necessary to care for its residents competently during day-to-day operations.

Inspectors wroteBased on facility staff education records and interview, the facility failed to implement and monitor an effective training program by ensuring Certified Nursing Assistants (CNA) attended the required abuse and dementia in-services for 2 of 5 selected CNA's. (#2 and #5).