Below average — CMS composite of the measures below.
The next survey window likely opens around November 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.
Uncovered Foley catheter bags were visible from the hallway for three residents with urinary catheters. Two residents had urine-filled bags exposed during observation, and a third resident was seen with a Foley bag resting on the floor with dark yellow urine visible despite a privacy bag hanging nearby. The resident’s care plan and provider order directed staff to keep the bag below bladder level and covered at all times to promote dignity.
Housekeeping and maintenance services were not adequately provided to keep the facility sanitary, orderly, and comfortable on the first and second floors. Surveyors observed a bed pan stored on the bathroom floor, a commode with a brown substance around the seat seam, scratched baseboards with exposed metal, and exposed wood on a door frame and windowsill creating uncleanable surfaces. The DON observed and later confirmed the maintenance concerns.
An IP prepared a syringe of Omeprazole in advance for one resident and removed it from the med cart during observation, despite stating that pre-preparing meds was against facility policy. In a separate observation, the IP prepared Lisinopril for a resident with HTN without first obtaining the required BP, overlooking the hold parameter in the order. The facility policy required meds to be prepared for one resident at a time and provider orders to be verified from the MAR.
Improperly Stored Chemicals in Resident Room: A resident had a bottle of OxiClean and a bottle of Betadine left on the dresser in the room on repeated observations. The resident said the OxiClean was used for clothing stains and the Betadine was used to clean hands. The surveyor discussed the improperly stored chemicals with the DON, but they were still observed on the dresser again the next day, and later with the DON and AA.
Unsanitary oxygen equipment and tubing storage: Two residents receiving O2 via nasal cannula were observed with dirty concentrators, including dust, dirt, and debris buildup on the machines and filter. One resident’s record had an order for weekly tubing changes but no evidence the filter was cleaned regularly. The DON stated there was no process for storing nasal cannulas or tubing when not in use, and tubing was being rolled up or hung on the concentrator without a bag.
The facility failed to consistently document AM and PM temperatures for the medication room refrigerator used to store insulin, vaccines, and other refrigerated meds. The refrigerator log showed multiple missed checks across several months, and the facility policy required daily temperature documentation for refrigerated meds stored at 36 F to 46 F. The DON acknowledged that the required temperature checks had not been consistently completed.
Incomplete CNA ADL documentation was identified for a resident, with repeated missing entries for bed mobility, toilet use, transferring, oral hygiene, personal hygiene, shower/bathe self, eating, bladder, and bladder elimination across multiple shifts. The DON and MDS Coordinator reviewed the records with the surveyor and confirmed that CNAs should document ADL care every shift.
Failure to Honor Resident Meal Preferences: The facility did not follow meal preferences for two residents. One resident repeatedly received eggs and hot cereal despite those items being listed as dislikes, and a surveyor observed hot oatmeal served at breakfast. Another resident said kitchen staff had never asked about likes and dislikes, even though the resident had been in the facility for over a month, and later stated a preference for more fresh fruit, vegetables, and rice.
A resident admitted with atherosclerosis with gangrene to both feet had skin findings of necrotic toes, a rash to the back and chest, and multiple wounds in various stages of healing. The medical record lacked evidence of a baseline care plan within 48 hours that included the instructions needed to properly care for the resident's wounds and skin issues, and the issue was discussed with the DON.
A resident’s care plan was not developed within 7 days after each comprehensive assessment for activities. Record review showed interdisciplinary team/care plan meetings were held before the MDS assessments were completed, and the LSW confirmed this during interview.
A resident who was dependent on one staff member for showers and needed partial moderate assist for personal hygiene was observed with oily, greasy hair. The resident was scheduled for weekly showers, but CNA documentation showed no showers were provided during the month reviewed, and the DON and MDS Coordinator confirmed there was no evidence of a shower being given.
Lack of Resident-Centered Activities Program: A resident reported having nothing to keep the mind busy and wanting paper to read or use. The activities care plan noted little or no activity involvement related to disinterest and physical limitations, but lacked interventions for mental stimulation or mental exercises. The Activities Director said she tries to offer at least 2 group activities daily and had only provided 2 magazines, though she could have offered more word search and similar materials.
Failure to follow a physician order for diabetes management. A resident with DM had an order for Lispro insulin after meals based on a sliding scale, but the MAR showed no evidence of evening BG monitoring after dinner on one date and no evidence that 2 units of Lispro were given when the BG was 208 on another date. The issue was discussed with the DON.
A resident with a G-tube had physician orders and a care plan requiring staff to verify tube placement and assess gastric residuals before giving meds, then flush the tube after administration. During observation, an IP administered medications through the G-tube without checking placement or residuals, and later acknowledged the required checks were not done.
Failure to provide ordered adaptive eating equipment. A resident with a puree diet, honey-thick liquids, aspiration precautions, strict supervision/assist, and an order to use a sippy cup was observed receiving a meal tray without the cup. The resident said sippy cups brought in by the son had gone missing, and the FSD acknowledged awareness of the missing cups despite the physician order and care plan intervention.
Food Storage and Sanitation Deficiencies: The facility failed to store and serve food in a sanitary manner. Surveyors found unlabeled and undated food items in the refrigerator, dietary staff wearing hair nets that did not fully cover their hair, and dust plus dirt/grease buildup on kitchen equipment. The emergency food supply in the basement was also reviewed, and the [NAME] stated more items likely needed to be brought down to feed 39 residents for 3 days.
Infection control practices were not maintained during medication administration, linen transport, and resident care. An IP failed to perform hand hygiene before and after entering a resident's room, and no EBP sign was posted. Laundry staff transported uncovered clean linens. Two residents who required EBP, including one with bilateral foot wounds and another with an indwelling foley catheter, had no EBP signage or PPE available at the room; one catheter bag was also observed resting on the floor.
A resident had a signed consent for the Pneumococcal vaccine, but the medical record lacked evidence that the vaccine was administered. The facility’s policy required eligible residents to be offered the vaccine series within 30 days of admission unless medically contraindicated or already vaccinated. The IP and DON confirmed the finding with the surveyor.
The facility staff failed to ensure that three residents had access to their call bell devices. One resident's device was hanging on the wall out of reach, another's was found on the floor, and the third's was pulled out of the wall and wrapped around the bed. The Infection Preventionist and surveyor confirmed these deficiencies, while other residents had access to their call devices.
The facility did not follow the printed menu for three days, affecting all residents. Residents expressed dissatisfaction with meal variety, noting repetitive weekly meals and lack of menu access. The cook admitted to not following the 4-week cycle menu, citing instructions from the manager and supply issues. The dietitian was unaware of these deviations, as her assessments were based on the published menus.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as stained ceiling tiles, dirty curtains, non-functional sinks, torn wallpaper, exposed heating elements, and equipment deficiencies. Additionally, the second floor had gouged ceiling tiles and an uncleanable handrail.
A facility failed to accurately code the MDS 3.0 for a resident with PTSD. Despite the resident's documented history of PTSD and related symptoms, the MDS inaccurately indicated no PTSD diagnosis. The surveyor found no information on potential PTSD triggers in the clinical record, and this issue was discussed with the Administrative Assistant.
A facility failed to create a care plan for a resident with PTSD, despite the resident's history of nightmares and trauma from an abusive relationship. The care plan lacked interventions to address PTSD symptoms, and the DON confirmed the absence of guidance for staff on avoiding re-traumatization.
The facility failed to provide trauma-informed care for two residents with PTSD, as trauma assessments were not conducted for non-veteran residents. One resident had a history of PTSD from an abusive relationship, while another exhibited distress likely stemming from childhood trauma. The facility lacked a trauma-informed care policy.
The facility failed to serve food at an appetizing temperature, as reported by residents and observed by surveyors. Residents complained about cold meals, lack of variety, and unappealing presentation. Food trays often sat in hallways before being distributed by CNAs, leading to cold meals. A food committee was formed to address these issues, and the DON acknowledged the problem.
The facility failed to notify a resident's physician and representative after unwitnessed falls, as required by their policy. One resident experienced two falls in one day without proper notification, and another resident had two separate falls with incomplete notifications. These issues were discussed with the RN Consultant.
The facility failed to conduct complete neurological assessments following unwitnessed falls for several residents, as required by their Head Injury Protocol. A resident had two unwitnessed falls on the same day, but a new assessment was not initiated after the second fall. Other residents also experienced unwitnessed falls with incomplete or missing assessments. The RN consultant confirmed these deficiencies.
The facility did not review and update its facility-wide assessment at least annually to determine necessary resources for competent resident care. The last review was in October 2022, with no evidence of further updates by October 2023. The DON confirmed this lapse.
The facility failed to ensure that the Administrator attended the required quarterly QAPI meetings. The QAPI council, as per the facility's plan, must include the Administrator and meet quarterly. Attendance sheets showed the Administrator missed five consecutive meetings, a finding confirmed by the DON.
Uncovered Foley Catheter Bags Visible From Hallway
Penalty
Summary
The facility failed to ensure the dignity of residents with urinary catheters by allowing uncovered urine-filled catheter bags to be visible from the hallway for 3 of 3 residents with catheters. During an initial observation on 12/1/25 at 9:15 a.m., Resident #1 and Resident #8 both had uncovered Foley catheter bags containing urine that could be seen from the hallway, and this was observed again at 9:30 a.m. by the surveyor and the charge nurse and confirmed with the DON. Later that morning, Resident #9 was observed lying in a low bed with a Foley catheter bag resting on the floor, containing dark yellow urine and visible from the hallway, even though a blue privacy bag was hanging next to it. The medical record for Resident #9 included a catheter care plan dated 6/6/25 directing staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, and a provider order dated 10/2/25 instructed nursing to cover the Foley cath bag at all times to promote dignity.
Housekeeping and Maintenance Deficiencies
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on both the first and second floors over 3 of 4 days of survey. Surveyors observed a shared bathroom for room [ROOM NUMBER] and 114 with a bed pan stored on the floor under the sink and a commode with a brown substance around the seam of the seat. Surveyors also observed scratches and exposed metal on the second-floor hallway baseboards, exposed wood on the inside of a door frame in resident room [ROOM NUMBER], and exposed wood on a windowsill in resident room [ROOM NUMBER], all described as creating uncleanable surfaces. The Director of Nursing was present for some of the observations and later confirmed the maintenance concerns.
Medication Administration Not Performed per Orders and Policy
Penalty
Summary
The facility failed to ensure medications were administered safely, accurately, and in accordance with provider orders and professional standards of practice for 1 of 3 medication administration observations reviewed. During an observation on the second floor, the Infection Preventionist removed a small plastic bag containing a syringe labeled Omeprazole for Resident #14 from the top drawer of the medication cart. When asked where the original medication bottle was and when the medication had been prepared, the Infection Preventionist stated he had prepared the Omeprazole syringe before starting the medication pass that morning and that the bottle was in the refrigerator at the first floor nurses station. He also stated that preparing medications in advance was not normal practice and was against facility policy and procedure. The same observation identified an issue with Resident #33, who was admitted with a diagnosis of Hypertension and had a physician order dated 10/24/25 for Lisinopril 10 mg by mouth daily, hold for systolic blood pressure below 100. During the medication administration observation, the Infection Preventionist prepared Lisinopril 10 mg for the resident and was about to leave the cart to administer it when the surveyor asked about the resident's blood pressure. The Infection Preventionist confirmed he had overlooked the order and had not obtained the resident's blood pressure that morning as required. The facility's Medication Administration Policy stated medications are to be prepared for one resident at a time, not pre-poured, and provider orders are to be verified from the MAR. In interview, the Administrator acknowledged that the blood pressure should have been obtained before administering the medication and that medications should not be prepared in advance.
Improperly Stored Chemicals in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards related to chemicals being properly secured. During observations on 12/1/25, 12/3/25, and 12/4/25, a bottle of OxiClean and a bottle of Betadine were observed on Resident #24’s dresser in the room. On 12/1/25, Resident #24 stated that the OxiClean was used to spray stains on clothing and the Betadine was used to clean hands. On 12/3/25, the chemicals were again observed on the dresser, and the surveyor and the DON discussed that the chemicals were not properly stored. On 12/4/25, the OxiClean and Betadine were again observed on the resident’s dresser, and later that day the surveyor discussed the improperly stored chemicals with the DON and the Assistant Administrator after they had already been addressed the day prior.
Unsanitary oxygen equipment and tubing storage
Penalty
Summary
The facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed. Resident #38 was observed receiving oxygen through a nasal cannula, and the concentrator filter was coated with a thick layer of dust. The resident’s medical record included an order for weekly nasal cannula tubing changes, but there was no evidence that the filter was being cleaned regularly. Resident #20 was observed receiving oxygen via nasal cannula, and the oxygen concentrator had a layer of dirt and debris built up over the top, by the handle, and along the area where the oxygen tubing attaches to the machine. An oxygen extension tubing was wrapped up and stored on the back of the concentrator with Velcro. During interviews, the DON stated the facility did not have a process for storing nasal cannulas and/or tubing when not in use and that tubing was usually rolled up and put under the handle, though bags could be requested to ensure a sanitary environment for storage. A later observation showed the concentrator cleaned, but the oxygen extension tubing was still hanging from it with Velcro and no bag.
Inconsistent Refrigerator Temperature Documentation for Refrigerated Medications
Penalty
Summary
The facility failed to ensure that temperature documentation was consistently completed for the medication room refrigerator used to store insulin, vaccines, and other refrigerated medications. Review of the Refrigerator Temperature Log Summary for June through December 2025 showed multiple missed AM and PM temperature checks, including 18 undocumented shifts in June, 17 in August, 21 in September, and 9 in October. The facility’s medication storage policy states that refrigerated medications, including insulin, vaccines, and other temperature-sensitive medications, must be stored at 36 F to 46 F, that nursing staff are responsible for monitoring refrigerator temperatures, maintaining organized storage areas, and reporting any temperature excursions immediately, and that temperatures must be documented daily. During an interview on 12/3/25 at 2:00 p.m., the DON acknowledged that the required AM and PM temperature checks for the medication room refrigerator had not been consistently completed.
Incomplete CNA ADL Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for one resident reviewed for ADL care. Review of the resident’s CNA documentation showed multiple omissions in ADL charting across October 2025 and November 2025, including missing documentation for bed mobility, toilet use, transferring, oral hygiene, personal hygiene, shower/bathe self, eating, bladder, and bladder elimination on numerous shifts. In October 2025, several ADL areas had 25 of 93 shifts without completed documentation, and bladder and bladder elimination had 21 of 93 shifts missing documentation. In November 2025, several ADL areas had 28 of 90 shifts without documentation, toilet use and personal hygiene had 29 of 90 shifts missing documentation, and bladder elimination had 27 of 90 shifts missing documentation. On 12/3/25 at 12:29 p.m., the DON and MDS Coordinator reviewed the documentation with the surveyor and confirmed that CNAs should be documenting every shift on ADL care being provided.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor resident meal preferences and self-determination for 2 of 3 sampled residents. Resident #29 stated that his/her food slip listed dislikes of eggs and hot cereal, but the facility continued to serve those items. On 12/3/25 at 8:06 a.m., a surveyor observed Resident #29 being served hot oatmeal for breakfast, and the food slip on the tray again listed eggs and hot cereal as dislikes. The Food Service Director later confirmed that Resident #29's choices were not being met. Resident #1 stated that kitchen staff had never visited and that he/she had not been asked about likes and dislikes. The medical record showed Resident #1 was admitted in early October 2025. The Food Service Manager stated that Resident #1 had not been in the facility very long and staff had not met with him/her, but the surveyor noted the resident had been there for over a month. Resident #1 later confirmed no kitchen staff had visited and stated a preference for more fresh fruit, vegetables, and rice, adding that they never have rice. The Food Service Manager acknowledged that anyone from the kitchen could interview a resident about likes and dislikes and confirmed that no one had yet seen the resident even after the earlier discussion.
Baseline Care Plan Not Developed for Resident With Gangrene and Multiple Wounds
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission that included the instructions needed to provide minimum healthcare information necessary to properly care for Resident #38. Resident #38 was admitted with a diagnosis of atherosclerosis with gangrene to both feet. A nurse's skin check dated 11/21/25 documented necrotic toes to both feet, a rash to the back and chest, and gangrene to both feet. The provider's history and physical dated 11/21/25 stated that the resident had bilateral lower extremities, anterior and posterior tibia, with multiple wounds in various stages of healing. As of 12/1/25, the medical record lacked evidence of a baseline care plan with the instructions necessary to properly care for the resident in the identified areas. The issue was discussed with the DON on 12/1/25 at 1:46 p.m.
Care Plan Meetings Held Before Completion of Comprehensive Assessments
Penalty
Summary
The facility failed to ensure that Resident #33’s care plan was developed within seven days after each comprehensive assessment for activities. Record review showed an MDS dated [DATE] with an interdisciplinary team/care plan meeting held on 10/20/25, which was 7 days before completion of the comprehensive assessment. A second MDS dated [DATE] showed an interdisciplinary team/care plan meeting held on 7/27/25, which was 1 day before completion of the comprehensive assessment. During an interview on 12/3/25 at 2:05 p.m., the Licensed Social Worker confirmed that both care plan meetings were held before the comprehensive assessments were completed.
Missed Scheduled Showers
Penalty
Summary
The facility failed to provide a whirlpool/shower/shampoo as directed by the resident's shower schedule for Resident #32. During observation on 12/1/25, the resident was seen with oily/greasy hair and stated that showers were not always given, although the resident said he/she had not recently refused a shower. Record review showed the resident was dependent on one staff member for showers and needed partial moderate assistance from one staff member for personal hygiene. The shower/whirlpool list updated on 11/30/25 indicated the resident was scheduled for a shower on Wednesday evenings, but CNA documentation showed no showers were provided during the month of November, when the resident should have received four showers. On 12/3/25, the DON and MDS Coordinator reviewed the documentation with the surveyor and confirmed there was no evidence that a shower was given during that month.
Lack of Resident-Centered Activities Program
Penalty
Summary
Provide activities to meet all resident's needs. Based on care plan reviews, observations, and interviews, the facility failed to provide a continuous resident-centered activities program for 1 of 4 residents reviewed for activity participation. Resident #1 stated that it would be nice to have something to keep the mind busy and that there was nothing available, adding that it would be nice to have a paper once in a while. Review of the resident's activities care plan, initiated on 10/13/25, showed that the resident had little or no activity involvement related to disinterest and physical limitations, and that the facility should establish and record prior activity involvement and interests, modify the daily schedule and treatment plan as needed to accommodate activity participation, and provide assistance or escort to activity functions. The care plan lacked interventions for mental stimulation, activities, or mental exercises. During interview, the Activities Director stated she attempts to have at least 2 group activities a day and, when asked about residents who do not participate in group activities, stated that she had given the resident 2 magazines but could have provided more and would try to get word search material and other items.
Failure to Follow Insulin Sliding Scale Orders
Penalty
Summary
The facility failed to follow a physician order for diabetes management for Resident #38, who was admitted in late November 2025 with a diagnosis of Diabetes Mellitus. Orders dated 11/20/25 directed nursing to administer Lispro insulin 100 units/mL subcutaneously after meals according to a sliding scale, including 2 units for a blood glucose of 200 to 249 and 0 units for 71 to 199. Review of the resident’s medication administration record showed no evidence of blood glucose monitoring for the evening after dinner on 11/24/25 and no evidence that Lispro insulin 2 units was administered on the evening of 11/26/25 when the resident’s blood glucose was 208. The issue was discussed with the DON on 12/3/25 at 9:21 a.m.
Failure to Verify G-Tube Placement and Residuals Before Medication Administration
Penalty
Summary
Appropriate treatment and services were not provided to prevent complications related to enteral feeding for one resident with a G-tube. Resident #14 had physician orders dated 10/13/25 directing staff to check G-tube placement and residual before administering medication and to flush the tube with 60 cc of water after medication administration; the orders also allowed crushed medications to be given together via the G-tube. The care plan stated the resident required total assistance from nursing staff for G-tube feedings and water flushes, including verifying tube placement and assessing gastric contents/residuals per facility policy. The facility policy for administering medications through an enteral tube also directed staff to check gastric residual volume to assess tolerance of enteral feeding. During a medication administration observation on 12/2/25 at approximately 8:30 a.m., the Infection Preventionist prepared and administered medications through the resident's G-tube without verifying tube placement or assessing gastric residuals before giving the medications. When interviewed immediately afterward, the Infection Preventionist acknowledged that tube placement or gastric residuals should have been assessed prior to administration, and this was confirmed with the Administrator later that morning.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who had physician orders and a care plan intervention for a sippy cup. Resident #29 was observed receiving a tray without a sippy cup, and the resident stated that the son had placed some sippy cups in the room but they had gone missing. The resident’s physician order dated 11/21/25 directed a Level 4 puree texture diet with honey consistency for aspiration precautions, strict supervision/assist, use of a sippy cup, and monitoring for left-side pocketing. The care plan dated 11/14/25 also included an intervention to use a sippy cup. When interviewed, the Food Service Director stated there was no order, but was aware of the missing sippy cups, and later confirmed that physician orders were in place for the use of a sippy cup.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to serve and store food in a sanitary manner on 2 of 4 survey days. During an initial kitchen observation, a container of applesauce, a sandwich, and a plate of eggs were found in the refrigerator unlabeled and undated, and the Kitchen Manager confirmed the finding. During another observation, dietary staff were seen wearing hair nets that did not encompass the entirety of their hair, which was confirmed by the Dietary Director. On a subsequent kitchen observation, a moderate amount of dust was observed on a wall-mounted fan, and there was a line above the stove with light to moderate dirt and grease buildup on the vents. The emergency food supply in the basement was also reviewed and included 6 #10 cans of beef stew, 3 large cans of tomato soup, 1 small can of tomato soup, 2 large cans of cream of mushroom soup, 1 #10 can of beans, 1 #10 can of kidney beans, 1 #10 can of beets, 1 12 oz box of pasta, and 1 #10 can of stewed tomatoes; when asked whether this was sufficient to feed 39 residents for 3 days, the [NAME] stated, "I think I need to bring more things down."
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and spread of infection during medication administration, linen handling, and use of Enhanced Barrier Precautions (EBP). During a medication pass, the Infection Preventionist prepared medications for a resident and left the medication cart without sanitizing his hands, entered the resident's room without performing hand hygiene, and did not have an EBP sign posted on the door. He donned a gown and gloves, administered medications via the gastrostomy tube, then removed the gown and gloves and exited the room without hand hygiene. The Infection Preventionist acknowledged he did not sanitize or wash his hands before entering or after exiting the room and stated an EBP sign should have been posted. The facility also failed to maintain infection control practices related to linen transport and resident-specific EBP precautions. Laundry staff were observed transporting clean linens that were not covered and confirmed they should have been covered during transportation. A resident with dry gangrene to both feet due to diabetes had multiple wounds in various stages of healing, necrotic toes, and a strong pungent odor to the feet, yet no EBP sign or PPE was posted or available at the room. Another resident with an indwelling foley catheter had the catheter bag resting on the floor, with no EBP sign or PPE available at the room, despite a care plan that included EBP interventions. The DON confirmed the catheter bag should have been in the privacy bag and that the resident should have had EBP posted with appropriate PPE available.
Failure to Administer Pneumococcal Vaccine After Signed Consent
Penalty
Summary
The facility failed to implement its Pneumococcal vaccine policy for 1 of 5 sampled residents, Resident #31. Record review showed that the resident had a signed consent to receive the Pneumococcal vaccine dated 7/18/25, but the medical record did not contain evidence that the vaccine was actually administered. The facility’s Pneumococcal Vaccine policy states that residents are to be assessed for eligibility prior to or upon admission and, when indicated, offered the vaccine series within 30 days of admission unless medically contraindicated or already vaccinated. On 12/4/25, the Infection Preventionist and DON confirmed the findings with the surveyor.
Failure to Provide Access to Call Bell Devices
Penalty
Summary
The facility staff failed to provide access to resident call bell devices for three out of thirty-five residents. During observations and interviews, it was noted that Resident #2 did not have a call device within reach, as it was hanging on the wall approximately five feet from the bed. This was corrected by a CNA who moved it to the resident's bed covers. Resident #3 was unable to locate their call bell, which was found with the cord behind them and the button on the floor between their chair and bed. Resident #4 was observed in bed without a call bell nearby, and a search revealed the device was pulled out of the wall and on the floor wrapped around the bed. The Infection Preventionist and surveyor confirmed that these three residents did not have access to a call bell, while the remaining residents did have access and knew where their call devices were located.
Failure to Follow Printed Menus and Provide Meal Variety
Penalty
Summary
The facility failed to adhere to the printed menu for three consecutive days during the survey, violating regulations S483.60(c)(2) and S483.60(c)(3), which require menus to be prepared in advance and followed. Observations and interviews with residents revealed dissatisfaction with the lack of variety and predictability in meals, as residents reported receiving the same meals weekly without access to a menu. The food committee meeting notes corroborated these complaints, indicating a desire for more variety and alternative choices beyond the usual egg salad or peanut butter and jelly. Interviews with the facility cook and the Director of Nursing highlighted a disconnect between the printed menu and the meals served. The cook admitted to not following the 4-week cycle menu, instead preparing meals based on instructions from the manager, who was on vacation. The cook also mentioned frequent deviations from the printed menu due to supply issues, such as the unavailability of chicken. The dietitian was unaware of these deviations, as her nutritional assessments were based on the published menus, which she assumed were being followed.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment across two units. On the first floor, the Upper Dining Room, hallway connecting the Upper and Lower Dining Rooms, living room, and resident hallway at the North end all had stained ceiling tiles. Specific resident rooms had issues such as dirty curtains with brown stains, non-functional sinks, stained ceiling tiles, torn wallpaper, and exposed heating elements. Equipment deficiencies included a sit-to-stand device with missing non-slip grips. On the second floor, the resident hallway had ceiling tiles with deep gouges and a handrail with bare and rough wood, creating an uncleanable surface.
Inaccurate MDS Coding for PTSD Diagnosis
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) 3.0 for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted to the facility, had a documented history of PTSD, as noted in the provider's admission progress note. This note detailed the resident's ongoing issues with nightmares and fear of leaving home, attributed to PTSD from a past abusive relationship. However, both the Admission MDS and the most recent Quarterly MDS inaccurately indicated that the resident did not have PTSD under the Active Diagnosis Section. The surveyor could not find any information in the clinical record regarding potential PTSD triggers that might cause re-traumatization for the resident. This discrepancy was discussed with the Administrative Assistant.
Failure to Develop PTSD Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted to the facility, has a history of nightmares and PTSD stemming from an abusive relationship and a traumatic divorce. The admission progress note highlighted the resident's ongoing issues with nightmares and fear of leaving home. However, a review of the resident's care plan revealed that it did not include any interventions or strategies to address the PTSD diagnosis. During an interview with the Director of Nursing, it was confirmed that there was no evidence of a care plan addressing potential triggers for the resident's PTSD symptoms or guidance for staff on how to avoid re-traumatization.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify and address the trauma history of two residents diagnosed with PTSD, leading to a deficiency in providing trauma-informed care. Resident #9's clinical record indicated a history of PTSD due to an abusive relationship and ongoing nightmares. Despite this, the Licensed Social Worker confirmed that trauma assessments were not conducted for residents other than veterans, which was discussed with the Director of Nursing. Similarly, Resident #31 exhibited distress and behavioral symptoms that interfered with care and social interactions. A hospice medical social worker noted that these behaviors likely stemmed from childhood trauma rather than dementia. However, the facility did not screen Resident #31 for trauma upon admission, as the facility's practice was to only screen veterans for trauma history. Additionally, the facility was unable to provide a trauma-informed care policy when requested by the surveyor.
Deficiency in Food Temperature and Variety
Penalty
Summary
The facility failed to serve food at an appetizing temperature to residents on both floors, as observed and reported by surveyors. Multiple residents expressed dissatisfaction with the temperature and variety of the food. One resident in the dining room mentioned that the food was not hot enough and seemed repetitive. Another resident, interviewed in bed, stated that breakfast was cold. A third resident showed a piece of cold French toast and complained about the lack of variety and unpredictability of meals. A resident who requested to speak with a surveyor noted that food trays often sat in the hallway for extended periods before being distributed by CNAs, leading to cold meals. This resident also mentioned the formation of a food committee to address these issues. The surveyor's observations during a lunch meal tray pass confirmed that trays were being distributed by CNAs, with no licensed staff assisting, despite a nurse's claim that they sometimes help. A CNA reported that by the time all trays were delivered and assistance was provided to those needing help, the food was no longer warm. The Director of Nursing acknowledged that food was an issue being addressed. A family member of a resident also confirmed the food temperature was not warm and noted poor variety. The food committee meeting notes highlighted concerns about cold food, melted ice cream, lack of variety, and unappealing presentation.
Failure to Notify Physician and Representative After Unwitnessed Falls
Penalty
Summary
The facility failed to notify a resident's physician and/or representative immediately following significant changes in the resident's medical condition, specifically after unwitnessed falls. According to the facility's policy, any unwitnessed fall should be treated under the Head Injury Protocol, which includes notifying the resident's physician and contact person. However, in the case of one resident, there were two unwitnessed falls on the same day, and there was no evidence that the physician or the resident's representative was notified after the second fall. This was confirmed when the resident's relative called the nurse for an update and inquired why they had not been informed. Another resident experienced unwitnessed falls on two separate occasions. In the first incident, the resident's legal guardian was notified, but there was no evidence that the physician was informed. In the second incident, the resident fell while attempting to use the bathroom, and although the nurse assessed the resident and found vital signs stable, there was no documentation of the legal guardian being notified. These lapses in communication were discussed with the RN Consultant during an interview.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to adequately assess and monitor residents following unwitnessed falls, as per their established protocols. The facility's policy requires that any unwitnessed fall, regardless of whether the resident is alert and oriented, be treated under the Head Injury Protocol. This protocol mandates a series of neurological assessments at specified intervals. However, the facility did not adhere to these protocols for several residents. Resident #1 experienced two unwitnessed falls on the same day. After the first fall, a neurological assessment was initiated, but it was not restarted after the second fall, as required. The resident later requested Tylenol for a headache, indicating a potential oversight in monitoring. The RN in charge acknowledged the failure to initiate a new neurological assessment after the second fall. Other residents also experienced similar deficiencies in care. Resident #3 had multiple unwitnessed falls over several months, with incomplete neurological assessments documented for each incident. Resident #4 had unwitnessed falls with missing incident reports and incomplete assessments. Resident #5 also had an unwitnessed fall with no evidence of a neurological assessment being completed. The RN consultant confirmed that the assessments were not completed as required for these residents.
Failure to Annually Review and Update Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment at least annually to determine the necessary resources for competent resident care during day-to-day operations. The Director of Nursing provided the surveyor with the facility assessment last reviewed in October 2022. However, there was no evidence of any further review or update by October 2023. This was confirmed during an interview with the Director of Nursing, who acknowledged that the review and revision of the facility assessment had not been completed since October 2022.
Administrator's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Administrator attended the required quarterly Quality Performance Improvement Committee meetings. According to the Coastal Manor Quality Assurance and Professional Improvement (QAPI) Plan, the QAPI council must include the Administrator and meet quarterly. A review of the attendance sheets revealed that the Administrator did not attend any of the five quarterly meetings held on 6/2/23, 9/18/23, 12/18/23, 1/29/24, and 3/18/24. This finding was confirmed during an interview with the Director of Nursing on 4/10/24.
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What surveyors actually found near you
We read the 196 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Yarmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brentwood Center For Health & Rehabilitation, Llc | 1.1 mi | ★★★★★ | 23 | 0 |
| Hawthorne House | 3.3 mi | ★★★★★ | 1 | 0 |
| Sedgewood Commons | 4.9 mi | ★★★★★ | 0 | 0 |
| Fallbrook Commons | 8.3 mi | ★★★★★ | 0 | 0 |
| Cedars Nursing Care Center | 8.8 mi | ★★★★★ | 1 | 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.