Coastal Oaks Special Care Center

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed in accordance with the facility's policies and procedures when an expired emergency medication kit was found stored in the medication store closet. This failure had the potential to result in reduced effectiveness and increased risk of side effects of the medications. Findings: During a concurrent observation and interview on 06/03/25 at 10:19 a.m. with the Director of Nursing, the facility's emergency drug kit was found stored in the medication storage closet with an expiration date of 6/2/25. The Director of Nursing stated the emergency kit should be replaced and not within the facility policy to have expired medications. During a review of the facility's policy and procedure (P&P) titled, Medication Storage: Storage of Medications, dated March 2024, the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers .are immediately removed from stock, disposed of according to procedures for medication disposal and reordered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the menu was followed as planned during lunch tray line (a system of food preparation in which trays move along an assembly line) when 2 residents (Resident 18 and 32) small portion diet were not followed. This failure had the potential not to meet the nutritional needs as planned to maintain normal body weight and acceptable nutritional values of residents. Findings: During a concurrent observation with the Dietary Manager (DM) on 5/06/24 at 11:58 a.m., of the lunch meal service in the kitchen steam table, part of the menu for the day (5/06/24),were cheesy mashed potatoes, carrots,and turkey. For the cheesy mashed potatoes, the scoops prepared for meal serving were #8 scoop (=1/2 cup) and a #16 scoop (=1/4 cup). For the diced and minced turkey, a 3-ounce spoodle was in place. During a concurrent observation and interview on 5/06/24 at 12:19 p.m., with the [NAME] (CK), in the kitchen, the meal cards for Residents 8 and 32 indicated ,small portion diet and 2 ounces of meat. CK was noted using scoop #8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to maintain medical records for three of 3 sampled residents (Resident 46, 38 and 44) and for one unsampled resident (Resident 47) were in accordance with professional standards and practices when: 1). Resident 46, physician ordered supplement intakes were not documented in the medical record. 2). Resident 38, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage ((SNFABN) notice of Medicare coverage ending) signature of resident representative was not legible or identified. 3) . Resident 44, Resident-Facility Arbitration Agreement ((RFAA) opting for a private dispute resolution procedure instead of going to court agreement) signature of resident representative was not legible or identified. 4). Resident 47, SNFABN date of notification was omitted. These failures had the potential to eflect a resident's progress towards achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status Findings: During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 22, 44, and 46) binding arbitration agreements had clearly stated the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and clearly stated the selection of a venue that is convenient to both facility and resident or resident representative. This failure had the potential to result in psychosocial harm in the event of an arbitration dispute. Findings: During a review of: Resident 22's RESIDENT-FACILITY ARBITRATION AGGREEMENT (RFAA), dated 7/8/21, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. Resident 44's RFAA, dated 11/21/22, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain essential equipment and safe operating condition, when the refrigerator gasket was found to have been torn. This failure resulted in the door not being able to seal appropriately and with potential to effect food temperatures. Findings: During a concurrent observation and interview on 05/08/24 at 02:46 p.m. of the snack shack refrigerator, the low-fat milk in the door was 48 fahrenheit (The standard scale used to measure temperature in the United States) when measured with the facility thermometer and verified by the Dietary Manager (DM) . The DM stated they took measurements to get a new refrigerator ordered. The DM Stated if they had seen the torn gasket then they would have notified maintenance about it for repair. During an interview and observation on 05/08/24 at 03:54 p.m. of the snack shack refrigerator, Facilities Manager (FM) stated he was not aware about the tear in the gasket. FM stated he would expect to be notified of this needing to be replaced by staff or in the maintenance logbook.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medication pass observation. record review, and interview the facility failed to ensure that it was free from a medication error rate greater than five percent when : 1. Resident 3 (Res 3) was ordered Aspirin (pain medication also use for blot clots) 81 mg delayed release (Enteric Coated -EC), but was given Aspirin 81 mg chewable. 2. Resident 46 was with orders for Aspirin 81 mg delayed release, but was given Aspirin 81 mg chewable. These failures resulted in a 5.41% medication error rate. Findings : During a medication pass observation conducted on 6/7/23, a total of 37 opportunites were observed /combination between two Licensed Nurses (LN), LN1 and LN2. 1. On 6/7/23, at 8:31 a.m., LN1 administered Aspirin 81 mg. chewable (form) to Res 3. During a review of the Medication Administration Record (MAR) for Res 3, on 6/7/23, at 10:27 a.m., the MAR indicated a physician order dated 11/24/22 of Aspirin 81 mg delayed release to be given one time daily for deep vein thrombosis (DVT - blot clots in veins) for prophylaxis. During an interview with LN1, on 6/7/23, at 3:12 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were stored at the right temperature in accordance with federal laws and the facility's policies and procedures. This failure had the potential for medications to lose potency and become ineffective. Findings: During a concurrent observation and interview, on 6/6/23, at 12:52 p.m., with the Director of Nursing (DON) and the Chief Nursing Officer (CNO), the medication refrigerator temperature was checked and noted to have the temperature read at 28 degrees Fahrenheit. The DON and CNO verified the temperature. The DON verbalized, the medication refrigerator was too cold and outside of temperature parameters. The CNO stated, It's too cold. Things will freeze. Insulin will crystalize below thirty-two degrees and no longer be effective. During a review of the facility's policy and procedures (P&P), titled, Nursing Care Center Pharmacy Storage of Medication, not dated, chapter 4, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the Registered Dietitian failed to demonstrate competency when the RD did not communicate current standards of practice to the facility's Medical Director, when the RD was aware a Low Concentrated Sweets (LCS) diet used at the facility was no longer nationally recognized, nor recommended to address residents diabetes. There were two of 12 sampled residents (Resident 48 and Resident 37) with an LCS diet order for nutrition care for diabetes. As a result, the RDs failed to utilize their expertise in the development of resident care policies and procedures to ensure that the facility provides care and services in accordance with current standards of practice, that address resident's diabetes diagnosis, and that provide clinical and technical direction to meet the needs of residents with a diagnosis of diabetes. Findings: During a concurrent observation and interview on 06/06/23, at 11:55 a.m., with Registered Dietitian (RD), in the kitchen, dietary staff were observed using a therapeutic menu/spreadsheet during the lunch trayline (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow the menu as planned, during lunch trayline (a system of food preparation in which trays move along an assembly line) when: 1. The small portion diet was not followed per the planned menu for one of 12 sampled residents (Resident 10). 2. The SB 6 (Soft, Bite Sized Food) diet was not followed related to the size of pork carnitas in accordance with the facility's planned menu, and Diet Manual for SB 6 diet, for one of 12 sampled residents (Resident 25). This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, not following the correct size of meat for a SB 6 diet had the potential to place the resident at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 06/06/23, at 12:04 p.m., with [NAME] 1, in the kitchen, [NAME] 1 was observed to use a two (2)-ounce (oz.) ladle to serve pork carnitas (diced pork per the recipe) onto Resident 10's lunch meal plate. The 2-oz.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.