Coastal Manor

Based 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. Findings include: Review of the facility's policy titled, Food and Supply Storage, dated 01/25, revealed All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Cover, label and date unused portions and open packages .Product is protected from the possibility of dust spinning upward during sweeping or mopping through the use of a solid barrier such as a sheet of plastic placed under products on the bottom shelf of open wire shelving .Dry Storage: Maintain designated area for items that…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's undated policy titled Transfer/Discharges stated purpose of the policy is to inform residents, family members, or legal representatives verbally and in writing (in a language and manner they understand) of reasons for a transfer or discharges. 1.Review of R17's Census tab located in the electronic medical record (EMR) revealed that R17 was discharged to the hospital on [DATE] and returned to the facility on [DATE]; discharged to the hospital on [DATE] and returned…

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, 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. Findings included: A facility policy titled, Abuse Prohibition, effective 02/27/2024, revealed E. Reporting Procedures - Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property the incident shall be immediately reported to the Nursing Home Administrator. 1. The Director of Nursing (or his/her designee) or Chief Long Term Care Officer a.k.a. [also known as] Nursing Home Administrator (or his/her designee) shall immediately notify the Complaint Investigation Intake and Referral Unit, the legal representative and/or interested family member, and the attending physician of the incident and the pending…

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, record review, and facility policy review, the facility failed to investigate 5 of 7 allegations of abuse perpetrated by a resident, Resident #2. Findings included: A facility policy titled, Abuse Prohibition, effective 02/27/2024, revealed F. Investigation - Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation or resident property, the following investigation and reporting procedures shall be followed: 1. The description of the alleged complaint is written on the investigation form. Any physical evidence and description of emotional state shall be documented. 2. Information gathering - The following information shall be gathered: a. Name of suspect b. Name of the resident c. Specific information about what happened d. Specific information about when it happened - include date and time of occurrence e. Specific information about where it happened f. Specific information about why it happened or any extenuating circumstances that you might have information about.…

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, 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. Findings included: A facility policy titled Abuse Prohibition, effective 02/27/2024, revealed, It shall be the policy of [facility name] to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. The policy specified, Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Per the policy, Physical Abuse - includes hitting, slapping, pinching and kicking. An admission Record indicated the facility admitted Resident #2 on 05/02/2024. According to the admission Record,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: A facility policy titled, Admissions (LTC), with an original date of 10/29/2001 and an effective date of 04/23/2024, indicated I. Introduction: The Admissions policy applies to residents admitted to the department of Long Term Care without regard to race, color, creed, national origin, age, sex, religion, handicap, ancestry, marital or veteran status, and/or payment source. The policy specified, H. Documentation for Medical Record: included f. PASARR Level I Evaluation. An admission Record indicated the facility admitted Resident #2 on 05/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, moderate intellectual disabilities,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. 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. During observations made on 03/06/2023 at 11:26 AM and 03/07/2023 at 2:24 PM, Resident #62 was lying in bed with half bed rails in the raised position on both sides of the bed. On 03/08/2023 at 9:00 AM the Director of Nursing (DON)…

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 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. Findings included: 1. Review of the facility policy titled, Food Handling Guidelines, revised February 2023, revealed procedures for thawing frozen meat/poultry/seafood and indicated the meat should be thawed Under running water: Submerged under potable running water at 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 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. Findings included: Review of a facility policy titled, Quality Assurance and Performance Improvement Program (QAPI), effective 02/25/2020, specified, Purpose of policy: A. To provide a proactive approach to continually improve resident care. B. To ensure a safe and secure environment for residents. The policy further indicated, The QAPI Program will provide for the safety and high quality with all clinical interventions while emphasizing autonomy…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. 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 9:00 AM, LPN #13 removed the plunger from the syringe and placed the plunger directly on the bed linen on the resident's bed,…

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 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. Findings included: A tour conducted on 03/06/2023 of four of six hallways revealed 53 of 59 occupied beds were observed with some type of bed rail, ranging from quarter rails to half rails. At the end of the day on 03/06/2023, the Director of Nursing (DON) was asked to provide bed rail assessments for six residents (Residents #43, #61, #55, #62, #17, and #41) who had bed rails in use on their beds. On 03/08/2023 at 9:00 AM, the DON provided Bed Rail/Assist Bar Evaluation forms for the six residents. The completed forms did not include inspection of bed frames, mattresses, and bed rails and no other evidence was provided indicating regular inspections were conducted. On 03/07/2023 at 4:37 PM, the DON stated the interdisciplinary team assessed the need for bed rails, and the…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of a facility policy titled, Care Plans, with an effective date of 10/27/2020, revealed, The Comprehensive Care Plan will provide direction to: 1. Incorporate identified problem areas: 2. Incorporate risk factors associated with identified problems; 3. Build on the resident's strengths; 4. Reflect treatment goals and objectives in measurable outcomes; 5. Identify the professional services that will be responsible for each element of care. The policy also revealed, The care plan will be used in developing the resident's daily care routines. The policy did not specifically address or mention the use of bed rails. 1. A review of a Face Sheet indicated the facility admitted Resident…

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 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. Findings included: Review of a facility policy titled, Administering Medications, dated 08/25/2020, specified, Medications will be administered in a timely manner and in accordance with the attending physician's written/verbal orders. 1. A review of a Face Sheet indicated the facility admitted Resident #25 with diagnoses that included dementia, peripheral vascular disease, and cerebrovascular disease. A review of Resident #25's Physician Orders, for the month of March 2023, revealed an order, dated 03/23/2022, for acetaminophen 325 milligrams (mg), one tablet by mouth once a day for pain. During observation of medication administration on 03/08/2023 at…

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.