Coastal View Healthcare Center

Inspectors wroteBased 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. During a concurrent observation and interview on 12/16/25 at 11:35 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive person-centered care plan (plan of care) was developed and implemented that included measurable objectives and timeframes for the use of psychotropic medication (drugs that alter brain chemistry to affect mood, thoughts, and behavior) for one of 11 sampled residents (Resident 9). This failure had the potential for Resident 9's medical, physical, mental and psychosocial needs (emotional, social - interaction with people, mental and spiritual well-being) not being met. In addition, placed Resident 9 at risk for possible unwanted side effects being overlooked without the appropriate plan of care for monitoring and necessary interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided in accordance with professional standards of practice when:1. Administering oxygen therapy without a valid physician order for one of six sampled residents (Resident 51). 2. Taking a blood pressure reading over a thick sweater for one of three sampled residents (Resident 55). This failure had the potential to result in placing the residents at risk for respiratory and circulatory (lung, heart, and blood/oxygen circulation) distress.1. During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 is a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including: chronic pulmonary edema (buildup of fluid in the lungs. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure timely reordering of a medication for one of three residents (Resident 48) when an opened and prescribed medication with a fill date of 8/23/25 was observed on the cart that should be ordered every 30 days. This failure resulted in resident not receiving his prescribed medication for the day.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 11 sampled residents (Resident 9) was free from unnecessary medication. This failure had the potential to result in Resident 9 acquiring possible unexpected medical complications related to the administration of an antidepressant (medication that affects mood) without the necessary monitoring for effectiveness and adverse side effects (unwanted, harmful medical outcomes) of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff followed sanitary food handling practices when male staff were working in the kitchen without using beard nets. This failure increased the potential risk for contamination in the food service area. During an observation on 12/15/25 at 8:50 a.m. in the kitchen, two male kitchen staff were observed handling tray carts and washing dishes without beard nets covering their facial hairs. During an interview on 12/15/25 at 9:05 a.m. with Kitchen Staff (KS) 1, KS 1 stated he does not use a beard net when working in the kitchen and only wears one when preparing food. During an interview on 12/15/25 at 9:10 a.m. with Kitchen Staff (KS) 2, KS 2 stated he does not use beard net while in the kitchen unless he is preparing food. During an interview on 12/15/25 at 9:15 a.m. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review and policy and procedure, facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment when 10 of 10 sampled residents (Residents 1, 2, 3, 10, 11, 12, 13, 14, 15, 16, and 17), did not have vital signs monitored as prescribed by the physician for COVID-19 prevention. This failure had the potential to result in delayed assessment to detect COVID-19 symptoms, increased risk of exposure and spread within the facility, compromised care for residents, and heightened the vulnerability of residents to severe health outcomes.

Inspectors wroteBased on interviews, record reviews and facility policy and procedure, the facility failed to ensure three of three sampled residents (Residents 1, 2, and 3), had their care plans (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) revised to include the fall prevention recommendations made by the Interdisciplinary Team (IDT -a health care team familiar with the resident and their needs). These failures resulted in Residents 1, 2, and 3's evolving needs for fall prevention not being met and potentially leading to preventable falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely responses to resident call lights. This failure had the potential for resident's needs going unmet and heightened the likelihood of falls within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall care plan intervention and follow physician orders for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experience negative outcomes in the event of a fall.

Inspectors wroteBased on interview, record review, and facility policy and procedure, the facility failed to ensure pain medication orders were followed to ensure adequate pain management for one of two sampled residents (Resident 1). This failure resulted in Resident 1 experiencing unnecessary pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) received hygiene care when the resident continually refused care and this was not reported to the doctor or resonsible party. This failure had the potential to result in Resident 1's hygiene needs not being met and sustaining skin complications.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a current copy of an advanced directive was in one out of 21 sampled residents (Resident 71) medical record. This failure had the potential to result in inaccurate treatment or intervention during an emergency medical situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation (a process in which a healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or treatment) was obtained prior to the use of bed rails for one of 21 sampled residents (Resident 25). This failure had the potential for Resident 25 to experience negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label/date a multidose vial once opened. This failure had the potential for an expired product to be administered to a resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper sanitary and food handling practices were observed while preparing food when: 1. A male employee, Dietary 1, with facial hair and without a beard net working in the kitchen. 2. Observed cook 1 preparing meatballs using an ice cream scoop while the container of seasoned ground beef was in a rectangular metal tray, observed inside the kitchen sink. 3. Observed Dietary 1 pushing trash can on wheels where food scraps were disposed around the kitchen without a cover/lid. This failure had the potential to result in the outbreak of foodborne illnesses (caused by eating food that has been contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean and disinfect a glucometer (an instrument that measures the concentration of glucose in the blood). This failure had the potential to spread disease to residents.

Inspectors wroteBased on and interview and record review for one of three sampled resident (Resident 1)'s MDS (Minimum Data Set ((MDS) - an assessment tool for residents in a nursing homes) the facility failed to assessment that must accurately reflect the resident's status for wandering (to move from place to place without a set path) behavior and wander alarm used for one of two sampled residents (Resident 1) was not accuratey document upon assessment when MDS indicated: 1. Resident 1 ' s MDS assessment for wandering behavior indicated that resdient had no behavior exhibited. 2. Resident 1 ' s MDS assessment for an alarm indicated that Resident 1 used the alarm daily from the 7-day look-back period requirement. These failures creates a situation whereby Resident 1 ' assessment did not reflect current satus which can delay and affect tratment.

Inspectors wroteBased on record review, interview and facility policy and procedure (P/P), the facility failed to ensure one of three sampled residents (Resident 1) health record was current and accurate with good medical and professional practice based on the service provided when: 1. Resident 1 ' s medical record fall history assessments documentation remained inconsistent. 2. Resident 1 ' s bowel and bladder (B&B) training assessment documentation remained inconsistent. This facility failure resulted Resident 1 ' s medical record not reflecting accurate fall assessments and bowel and bladder (B&B) assessments and had the potential for Resident 1 to not receive adequate care to meet Resident 1 ' s needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff has completed their annual skill competencies on the following topics: Mechanical Ventilation (a machine that assists a patient to breathe), Oral and Dental Assessments, Licensed Nurse Checklist, Neurological Care (care to patients with brain or neurological problems), Enteral Feeding (nutritional support through a feeding tube) and Skills Check List. This facility failure had the potential for residents to receive sub-standard quality of care.

Inspectors wroteBased on record review, and interview, the facility failed to ensure staff received annual mechanical ventilation (a machine that helps a patient breathe when he or she cannot breathe on his or her own) competencies according to policy and procedure. This facility failure had the potential for residents on ventilators to receive sub-standard quality of care.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Resident 46 received the Restorative Nursing Assistant (RNA) treatments per physician orders. 2. Resident 58 received the RNA treatments as ordered by the physician. 3. Resident 31 Occupational Therapy recommendation for RNA exercises was relayed to the attending physician for orders. 4. Resident 42 received proper Gastrostomy Feeding (GT- nutritional tubing inserted in the abdomen) care per facility's policy and procedure. These failures placed Residents 46, 58, and 31 at increased risk for decreased muscle strength, decreased range of motion, contractures and possible decline in function, and Resident 42 at risk for aspiration (feeding formula to lungs).

Inspectors wroteBased on interview and record review the facility failed to ensure staffing for restorative nursing assistants (RNA- personnels trained to render range of motion exercises to residents as ordered by the physician) was adequate to render the treatments as ordered by the physician for the residents. This failure had resulted to residents missing RNA treatments placing them at risk for contratures, and decreased mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were palatable to ensure resident's satisfaction for one of 24 sampled residents (Resident 63), and for approximately five to six residents who attend a dining committee as reported by the Dietary Services Supervisor (DSS).

Inspectors wroteBased on interview and record review the facility failed to ensure evidence was in place that informed consents (authorization from residents or responsible party) were obtained and completed prior to the administration of psychotropic medication ( medications that affects behavior, mood, thoughts,or perception) in one resident (Resident 190). This failure had the potential to deny the resident the opportunity to know the risks and benefits of taking the medications which is part of the resident's right to know.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Representatives of the office of the state long-term care Ombudsman were informed or notified of the residents ongoing and recurring resident council meetings (RCM). This failure has the potential for residents to have no patient advocate present when conducting their council meetings especially when airing their concerns regarding care in the facility. 2. The Resident council meeting minutes (RCMM) presented by the facility to the resident council (RC) president to be signed and dated should be on the month and date the RCM was conducted to prevent back dating. This failure has the potential for the RC president to not know exactly what RCMM dates the signature requested is for with risk for fraudulent recordings of the RCMM. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a completed Minimum Data Set (MDS, an assessment tool) was transmitted in a timely manner for three residents (Residents 12,3 and 2). This facility failure resulted in non-compliance with the regulatory requirements for MDS transmission.and with the potential for records unaccountablility of resident ' s whereabouts and current conditions.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS-resident care assessment tool) for three out of 24 sampled residents when: 1. Resident 46's Section I (Active diagnoses) was not documented accurately 2. Resident 58's Section I (Active diagnoses) was not documented accurately 3. Resident 25's Section O (Special treatments, procedures, and programs) were not documented accurately This failure resulted in the documentation of inaccurate assessments and had potential of unmet care needs for Resident 46, Resident 58, and Resident 25.

Inspectors wroteBased on interview and record review the facility failed to 1. Develop an appropriate person-centered care plan when Resident 60 was NPO (nothing by mouth), on G-tube (gastrostomy tube-a tube inserted through the belly that brings nutrition directly to the stomach) feedings, and had weight loss. 2. Ensure an intervention of high calorie snacks, on Resident 187's IDT nutritional care plan, was implemented. These failures had the potential for unmet nutritional needs and weight loss for Resident 60 and Resident 187, and risk of aspiration for Resident 60.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the planned menu and/or meal tray card (guidance to staff on what to serve for a meal to a resident) was accurate and followed for two of 24 sampled residents pertaining to: 1. A health shake order for Resident 187. 2. A low-potassium diet for Resident 7. This facility failure had the potential to not meet the resident's nutritional needs per the planned menu and/or planned meal tray card.

Inspectors wroteBased on record review and interview the facility failed to ensure resident's care of being turned every 2 hours was accurately documented as care planned in the medical record of one resident of 24 sampled residents (resident 42). This failure had the potential for the resident's condition and care to be misrepresented.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices when: 1. A nasal cannula and tubing for oxygen administration for one resident (Resident 188) was found on the floor and there was no date on the tubing. 2. A shower chair that is shared between residents had red smear marks on it. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition.