Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Manor during CMS and state inspections, most recent first.
Surveyors found that food was stored directly on the freezer floor, opened food items were not labeled or dated, and the commercial can opener had dried debris on the blade. Additionally, a large flour bin was left uncovered, and dented cans were stored with regular pantry items and used to prop open a door. The Dietary Manager and Registered Dietician confirmed these practices did not meet facility policy or professional standards.
The facility did not provide written notifications of hospital transfers to three residents or their representatives, as required by policy. Instead, staff relied on verbal communication and chart notes, with no evidence of written notices in the EMR. One resident confirmed never receiving such a notice, and staff interviews revealed a lack of awareness of the written notification requirement.
The facility failed to report allegations of abuse involving a resident with a history of aggression and cognitive impairments. Despite multiple incidents of the resident hitting, pinching, and attacking others, these were not reported to the Administrator or state survey agency as required. Staff interviews revealed inconsistent reporting, and the facility chose not to investigate further after the resident's discharge.
A resident with a history of physical aggressiveness and behavioral issues was involved in multiple incidents of abuse towards other residents. Despite documented incidents of hitting, pinching, and unprovoked attacks, the facility failed to investigate or document these allegations as required by their policy. Interviews with the DON and Administrator revealed inconsistencies in the investigation process, and the facility chose not to pursue investigations after the resident was discharged.
A resident with a history of violent behavior and cognitive impairments physically abused other residents, leading to a deficiency in protecting residents from harm. The facility failed to report and investigate incidents in a timely manner, and interventions to manage the resident's behavior were insufficient. The DON admitted that some incidents were not reported within the required timeframe, and the facility did not contact the police unless there was major physical harm.
A resident with a history of intellectual disabilities and behavioral issues was admitted without a required PASARR screening. The facility's policy mandated this evaluation, but it was not completed due to the resident's admission under respite care. Attempts to obtain the screening were denied by state agencies, as the facility was deemed inappropriate for the resident.
Deficient Food Storage, Labeling, and Equipment Sanitation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility's kitchen. Cardboard boxes containing frozen food were found stored directly on the walk-in freezer floor, contrary to facility policy and professional standards, as confirmed by the Dietary Manager (DM) and Registered Dietician (RD). Opened boxes of spicy chicken breast and beef patties in a reach-in freezer were not labeled or dated, and the DM acknowledged that these items should have been properly protected and identified. Additionally, the commercial can opener was repeatedly found with dirt and dried debris on the blade during multiple inspections, and a large dry bin of flour was observed with a lid that did not fit properly, leaving the contents exposed to air. Further inspection of the pantry revealed several dented cans of food stored among regular use items, rather than being separated for return or disposal as required by policy. One dented can was even used to prop open a pantry door and was found on the floor. The DM confirmed that dietary staff were expected to monitor and segregate dented cans upon delivery, but this was not done. These deficiencies in food storage, labeling, equipment cleanliness, and handling of damaged goods had the potential to affect all residents consuming food from the kitchen.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to the hospital for three residents, as required by policy and regulation. Record review showed that for each of these residents, there was no evidence in the electronic medical record (EMR) that a written notice of transfer was given or sent to the resident or their representative. Specifically, one resident was discharged to the hospital on two occasions, another was hospitalized multiple times, and a third was transferred to an acute hospital due to lethargy and being difficult to arouse. In each case, there was no documentation of a written notification of transfer in the EMR. Interviews with facility staff, including the DON, Social Services Coordinator, and Administrator, confirmed that the facility's practice was to call the family and note it in the chart, but not to send written notifications to the resident or their representative. One resident also denied ever receiving a written notice of transfer or discharge. The facility's policy requires informing residents, family members, or legal representatives verbally and in writing of the reasons for transfer or discharge, but this was not followed for the residents reviewed.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that staff reported allegations of abuse immediately to the Administrator or designee and did not report these allegations to the state survey agency. This deficiency was observed in five out of seven reviewed allegations of abuse. The facility's policy on abuse prohibition required immediate reporting of incidents involving alleged mistreatment, neglect, or abuse to the Nursing Home Administrator and the state survey agency within 24 hours. However, several incidents involving Resident #2, who had a history of physical aggressiveness and cognitive impairments, were not reported as required. Resident #2, admitted on 05/02/2024, had a medical history including autistic disorder, moderate intellectual disabilities, and violent behavior. The resident exhibited aggressive behaviors towards other residents on multiple occasions, including hitting, pinching, and attacking without provocation. Despite these incidents being documented in progress notes, there was no evidence that they were reported to the Administrator or the state survey agency. Interviews with staff, including LPNs and the DON, revealed a lack of consistent reporting and awareness of these incidents. The facility's failure to report these incidents was further compounded by the decision not to investigate or report them after Resident #2 was discharged. The DON acknowledged that some incidents were not reported or investigated, and the facility decided not to pursue them further due to the resident's discharge and the elapsed reporting timeframe. This decision was made despite the facility's policy and the requirement to report such incidents to the state survey agency within a specified timeframe.
Failure to Investigate Allegations of Abuse by Resident
Penalty
Summary
The facility failed to investigate five out of seven allegations of abuse perpetrated by a resident, identified as Resident #2. The facility's policy on abuse prohibition required a thorough investigation and documentation of any alleged mistreatment, neglect, or abuse. However, the facility did not follow these procedures for incidents involving Resident #2, who had a history of physical aggressiveness and behavioral issues related to autistic disorder and moderate intellectual disabilities. The resident's care plan included monitoring behavior episodes, but the facility did not adequately investigate or document the incidents of abuse reported in the progress notes. Resident #2 was admitted to the facility with a medical history that included autistic disorder, moderate intellectual disabilities, and violent behavior. The resident's progress notes documented several incidents where Resident #2 physically assaulted other residents, including hitting, pinching, and attacking without provocation. Despite these documented incidents, the facility did not conduct interviews with staff or gather written statements as required by their policy. The Director of Nursing (DON) admitted that some incidents were not reported or investigated, and the facility decided not to pursue investigations after Resident #2 was discharged. Interviews with the DON and the Administrator revealed inconsistencies in the facility's process for conducting abuse investigations. The DON stated that the decision to document statements depended on the perceived pertinence of the information, and the facility only contacted the police for resident-to-resident incidents if there was major physical harm. The Administrator confirmed that the DON was responsible for completing abuse investigations and that the facility chose to educate staff rather than investigate the incidents after Resident #2's discharge. The facility's failure to investigate these allegations of abuse violated their own policy and left the incidents unaddressed.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, identified as Resident #2, who had a history of violent behavior and cognitive impairments. Resident #2 was involved in multiple incidents of physical aggression towards other residents, including hitting, scratching, and grabbing. These incidents affected three residents, who were identified as having varying degrees of cognitive impairment and medical conditions such as dementia and cerebrovascular disease. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the lack of timely reporting and investigation of the incidents involving Resident #2. Staff interviews revealed that some incidents were not reported to the Director of Nursing (DON) or investigated, and the facility did not consistently follow its policy to protect residents from abuse. The DON admitted that some incidents were not reported within the required timeframe, and the facility did not contact the police for resident-to-resident abuse unless there was major physical harm. The facility's failure to address Resident #2's aggressive behavior and protect other residents from harm resulted in a deficiency. Despite the facility's awareness of Resident #2's history of aggression, interventions to monitor and manage the resident's behavior were insufficient. The facility's decision not to report or investigate some incidents after Resident #2 was discharged further highlights the deficiency in protecting residents from abuse.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) was completed for a resident with a history of autistic disorder, moderate intellectual disabilities, and other behavioral issues. The resident was admitted to the facility on May 2, 2024, and the admission Minimum Data Set (MDS) indicated moderately impaired cognitive skills and behavioral symptoms. Despite these indicators, there was no evidence of a PASARR screening conducted on or before admission or after the resident remained in the facility for more than 30 days. The facility's policy required a PASARR Level I Evaluation as part of the admission documentation, but this was not completed. The Director of Nursing (DON) stated that the resident was admitted under respite care, and when the facility attempted to obtain a PASARR, state agencies indicated the nursing facility was not appropriate for the resident and denied the completion of the screening. The lack of a PASARR screening was acknowledged by the Administrator and the DON, highlighting a failure to comply with the expected procedure for all residents prior to admission.
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What surveyors actually found near you
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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 Ludowici
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jesup Ridge Of Journey Llc | 9.2 mi | ★★★★★ | 0 | 0 |
| Altamaha Healthcare Center | 12.1 mi | ★★★★★ | 7 | 0 |
| Harborview Health Systems Jesup | 12.2 mi | ★★★★★ | 7 | 0 |
| Glenvue Health & Rehab | 19.3 mi | ★★★★★ | 0 | 0 |
| Magnolia Manor Of Midway | 21.1 mi | ★★★★★ | 12 | 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.