A list of the most recent deficiencies for Coastal Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-14 | 2024-01-02 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-27 | 2023-05-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-27 | 2023-05-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-27 | 2023-05-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-27 | 2023-05-11 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-03-27 | 2023-05-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-27 | 2023-05-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-19 | 2022-11-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-21 | 2022-11-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-09-21 | 2022-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-21 | 2022-11-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-21 | 2022-11-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-21 | 2022-11-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-21 | 2022-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-21 | 2022-11-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-09-21 | 2022-11-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-21 | 2022-11-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-21 | 2022-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-21 | 2022-11-05 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-21 | 2022-11-05 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-21 | 2022-11-05 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-07 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-22 | 2022-01-21 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-22 | 2022-01-21 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-04 | 2020-03-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-03-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-04 | 2020-02-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-06 | 2020-02-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-03-10 | 2019-04-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-13 | 2019-03-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-03-13 | 2019-03-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-03-13 | 2019-03-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-13 | 2019-03-20 | N |
