Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coastal Oaks Special Care Center during CMS and state inspections, most recent first.
During a facility inspection, an unsealed four-inch penetration was found in the ceiling of the electrical room, with a conduit passing through. The Maintenance Consultant stated that this resulted from recent utility upgrades where the vendor did not seal the opening after completing their work. The deficiency affected one of two smoke compartments.
Surveyors found that a sprinkler pendant in a shower room was corroded and discolored, and required signage was missing from the sprinkler backflow piping and Fire Department Connection (FDC). The Maintenance Consultant explained the corrosion was due to shower moisture and believed signage was unnecessary since only one building was connected. These issues affected all residents and both smoke compartments.
Surveyors found that a corridor door to the small dining room did not fully close, leaving a half-inch gap between the door and frame. The Maintenance Consultant noted ongoing building shifting as a likely cause. This failure to maintain the door compromised the smoke compartment's integrity as required by NFPA 101.
Surveyors found that an electrical outlet near a waterline was not GFI-protected, a damaged outlet faceplate was present in a resident room, and GFI outlets were not tested according to manufacturer instructions. Staff were unaware of these issues, and the deficiencies affected multiple residents and smoke compartments.
An expired emergency medication kit was found stored in the medication storage closet, contrary to facility policy requiring immediate removal and disposal of outdated medications. The DON confirmed the kit should have been replaced and that expired medications are not permitted per facility procedures.
The facility failed to follow the prescribed menu for two residents on a small portion diet during lunch service. The cook used incorrect scoop sizes for cheesy mashed potatoes and served more turkey than ordered. This discrepancy was confirmed by the Dietary Manager and had the potential to affect the residents' nutritional needs.
The facility failed to maintain accurate medical records for three sampled residents and one unsampled resident, including missing documentation of supplement intakes, illegible and unidentified signatures on important documents, and missing dates on notifications.
The facility failed to ensure that the binding arbitration agreements for three residents clearly stated the selection of a neutral arbitrator agreed upon by both the facility and the resident or resident representative, and the selection of a convenient venue. The Administrator acknowledged the missing verbiage during an interview.
The facility failed to maintain essential equipment when a refrigerator gasket was found to be torn, causing the door not to seal properly and potentially affecting food temperatures. The issue was not reported in the Maintenance Repair Log, and both the Dietary Manager and Facilities Manager were unaware of the problem.
Unsealed Ceiling Penetration in Electrical Room
Penalty
Summary
A deficiency was identified during a facility tour and interview with the Maintenance Consultant, where an unsealed penetration was observed in the ceiling of the electrical room. The penetration, approximately four inches in size, was located on the south side of the electrical room ceiling, with a conduit passing through the space. This condition was noted during an inspection and was directly observed by the surveyor. The Maintenance Consultant explained that the facility had recently undergone utility upgrades, and the vendor responsible for the work failed to seal the penetration after completing the project. This unsealed opening was present in one of two smoke compartments within the building. No information was provided regarding any residents or their medical conditions in relation to this deficiency.
Sprinkler System Maintenance and Signage Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 requirements. During a tour of the building, a sprinkler pendant in the shower room adjacent to the MDS Office was observed to be green, corroded, and had a green-tinted fusible link. The Maintenance Consultant attributed the corrosion to moisture and steam from the showers. Additionally, the inspection revealed that the sprinkler backflow piping and Fire Department Connection (FDC) were missing the required signage to indicate the system or portion of the system they control. The Maintenance Consultant stated that the missing signage had not been previously cited and believed it was unnecessary due to the building being the only structure connected to these pipes. These deficiencies affected all five residents and both smoke compartments in the facility. The lack of proper maintenance and required signage on the sprinkler system components was directly observed and confirmed through staff interviews during the survey.
Plan Of Correction
NFPA 101 Life Safety Code Standards K353 Sprinkler Maintenance and Training The sprinkler pendant in the shower room was replaced and a sign with the facility address was placed on the sprinkler backflow piping. (See attached photos) To monitor the fire sprinkler pendants in the building and to verify that the signage is on the backflow piping, the Director of Maintenance will perform a monthly audit for 3 months. The Administrator will review the monthly audits and bring the findings to the Quality Assurance Team on a quarterly basis to evaluate the effectiveness of the program. This corrective action was completed June 20th, 2025. K 353
Corridor Door Fails to Fully Close, Creating Gap in Smoke Compartment
Penalty
Summary
During a facility tour, surveyors observed that the door to the small dining room, when closed, left an approximately one-half inch gap between the door leaf and the doorframe. This observation was made in the presence of the Maintenance Consultant, who attributed the gap to the continual shifting of the building structure. The report specifies that this issue affected one of two smoke compartments in the facility. The deficiency was identified as a failure to maintain corridor doors in accordance with NFPA 101: Life Safety Code requirements. Specifically, the door did not fully close, which could delay the prevention of smoke spread during an emergency. The report does not mention any residents or staff being directly involved or affected at the time of the observation, nor does it provide any additional medical history or conditions related to individuals.
Plan Of Correction
NFPA 101 Life Safety Code Standards K 363 Corridor- Doors The corridor doors were adjusted and the gaps were fixed (See attached photos). The Director of Maintenance will audit the corridor doors weekly, ensuring that the fire doors are free of gaps and close completely for the next 3 months. The Administrator will review the audits and bring findings to the Quality Assurance Team on a quarterly basis to evaluate the effectiveness of the program. This corrective action was completed June 20th, 2025.
Deficiencies in Electrical Outlet Safety and Maintenance
Penalty
Summary
Surveyors identified several deficiencies related to electrical outlets during a facility tour, document review, and staff interviews. In the auxiliary space between two resident rooms, an electrical outlet located beneath a waterline and connected to a refrigerator was found to lack Ground Fault Interrupter (GFI) protection. The Environmental Consultant was unaware of this issue and stated it had not been noted in previous life safety surveys. Additionally, in a resident room, a damaged and bent electrical outlet faceplate was observed, which was not flush with the outlet. The Maintenance Consultant was also unaware of this damage. Further review of documentation revealed that GFI outlets were being tested only annually, despite the manufacturer's instructions on the outlet cover indicating that testing should occur monthly. The Maintenance Consultant confirmed that all outlets were tested annually and was not aware of the monthly testing requirement. These deficiencies affected three of five residents and one of two smoke compartments, as noted in the findings.
Plan Of Correction
The outlet in the Snack Shack was replaced with a GFI receptacle. The wall plate in the resident room was replaced that afternoon. (See attached photos.) The Director of Maintenance will audit the electrical receptacles throughout the building monthly and ongoing, to ensure that each receptacle is in proper working order. The Administrator will review the audits quarterly and bring findings to the Quality Assurance Team as part of the QAPI safety program evaluating the effectiveness. This corrective action was completed June 20th, 2025.
Expired Emergency Medication Kit Found in Storage
Penalty
Summary
Surveyors observed that an expired emergency medication kit was stored in the facility's medication storage closet. During a concurrent observation and interview, the Director of Nursing confirmed that the emergency kit had an expiration date that had already passed and acknowledged that it should have been replaced. The facility's policy and procedure on medication storage, dated March 2024, requires that outdated, contaminated, or deteriorated medications be immediately removed from stock, disposed of according to proper procedures, and reordered from the pharmacy. The presence of the expired emergency medication kit in the storage area was not in accordance with the facility's own policies and procedures. The Director of Nursing confirmed that having expired medications on hand was not within facility policy. No information was provided in the report regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
F 761 Label/Store Drugs and Biologicals 1. The Medication E-Kit was removed from service immediately, Pharmacy was notified and new Medication E-Kit was replaced the same afternoon by Director of Nursing 6/3/2025. 2. The Director of Nursing completed an audit of all the medication E-Kits in the facility ensuring that all were within compliance. 3. Facility will be conducting weekly rounds by the Director of Nursing and/or designee to assure deficient practice doesn't occur again verifying the dates on the Medication E-Kits in the facility. 4. Findings will be brought to the Quality Assurance Committee by the Director of Nursing and/or designee on a quarterly basis for recommendations. 5. The corrective action will be completed by June 13th.
Failure to Follow Prescribed Menu for Small Portion Diet
Penalty
Summary
The facility failed to ensure the menu was followed as planned during the lunch tray line service for two residents on a small portion diet. During an observation of the lunch meal service, it was noted that the meal cards for the two residents indicated a small portion diet with 2 ounces of meat. However, the cook used a #8 scoop (1/2 cup) for the cheesy mashed potatoes instead of the required #16 scoop (1/4 cup) and served 3 ounces of diced/minced turkey instead of the ordered 2 ounces. This discrepancy was confirmed by the Dietary Manager when the meal carts were about to leave the kitchen. The cook stated, through the Dietary Manager's translation, that they were not aware of the specific scoop sizes required for the small portion diet. A review of the facility's Spring/Summer 2024 Diet Spreadsheet menu confirmed that the small portion diet should include 2 ounces of roasted thyme turkey and 1/4 cup of cheesy potatoes. The failure to follow the prescribed menu had the potential to not meet the nutritional needs of the residents as planned, which could affect their normal body weight and acceptable nutritional values.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards for three sampled residents and one unsampled resident. For Resident 46, the physician-ordered supplement intakes were not consistently documented in the medical record, with only nine days of recorded intakes over a period of more than a month. Interviews with staff revealed that CNAs were responsible for documenting meal and supplement intakes, but there was a lack of consistent documentation. The facility's policy required nursing staff to supervise and record supplement consumption, but this was not adhered to in practice. For Resident 38, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) had an illegible signature of the resident representative without identification. Similarly, Resident 44's Resident-Facility Arbitration Agreement (RFAA) also had an illegible signature without identification. Additionally, Resident 47's SNFABN was missing the date of notification. The Administrator confirmed these documentation issues during interviews, acknowledging that signatures should have been legible and identified, and dates should have been recorded.
Deficiency in Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the binding arbitration agreements for three sampled residents (Residents 22, 44, and 46) clearly stated the selection of a neutral arbitrator agreed upon by both the facility and the resident or resident representative, and the selection of a venue that is convenient to both parties. This deficiency was identified during a review of the residents' arbitration agreements, which were dated 7/8/21, 11/21/22, and 4/7/23, respectively. During an interview on 5/8/24, the Administrator acknowledged that the required verbiage was missing from the agreements.
Failure to Maintain Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition when a refrigerator gasket was found to be torn, resulting in the door not sealing properly and potentially affecting food temperatures. During an observation and interview, the low-fat milk in the refrigerator door was measured at 48°F, which was verified by the Dietary Manager (DM). The DM stated that they had taken measurements to order a new refrigerator but had not noticed the torn gasket. The Facilities Manager (FM) was also unaware of the issue and stated that he would expect to be notified by staff or through the maintenance logbook. A review of the Maintenance Repair Log from 7/25/23 to 5/7/24 showed no reports of the torn gasket. The facility's undated policy on Maintenance Preventative Maintenance Program indicated that minor defects should be detected and corrected before developing into serious problems, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Atascadero
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineyard Hills Health Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Bayside Care Center | 12 mi | ★★★★★ | 4 | 0 |
| San Luis Transitional Care | 12.6 mi | ★★★★★ | 0 | 0 |
| San Luis Post Acute Center | 13.1 mi | ★★★★★ | 1 | 0 |
| Mission View Health Center | 13.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.