20 Reports
Inspection Report — Dec 16, 2025
Complaint Investigation
Date: Dec 16, 2025
Visit Reason
An unannounced on-site visit was conducted for the purpose of investigating complaint #268437.
Findings
There were no regulatory violations identified as a result of the 12/16/25 investigation.
Report Facts
: 268437
Inspection Report — Dec 2, 2025
Biennial Survey
Date: Dec 2, 2025
Visit Reason
Federal Recertification Survey of Coastal Manor long-term care facility.
Findings
Coastal Manor is not in substantial compliance with 42 CFR 483.73 Emergency Preparedness and NFPA 101 Life Safety Code 2012 Edition. Deficiencies were found in emergency preparedness plan reviews, risk assessments, subsistence needs, volunteer use, arrangements with other facilities, training and testing programs, emergency power systems, fire drills, corridor door smoke resistance, construction separations, egress door locking, stairway handrails, emergency lighting, trash container storage, and fire door maintenance.
Deficiencies (18)
E0004: The facility failed to conduct the annual review of the Emergency Preparedness Plan since July 30, 2024.
E0006: The facility failed to maintain a risk assessment for the Emergency Preparedness Plan and did not update it annually.
E0007: The Emergency Preparedness Plan did not address resident population, types of services provided in emergencies, and continuity of operations including delegations of authority and succession plans.
E0015: The facility failed to maintain provision of subsistence needs for staff and patients including medical supplies, pharmaceuticals, fuel for heating, food, and water.
E0024: The facility failed to include policies and procedures for the use of volunteers and emergency staffing strategies to address surge needs during an emergency.
E0025: The facility failed to develop arrangements with other facilities or providers to receive patients in the event of limitations or cessation of operations to maintain continuity of services.
E0037: The facility failed to maintain an emergency preparedness training program including documentation, periodic training, and staff knowledge verification.
E0039: The facility failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills.
E0041: The facility failed to implement emergency and standby power systems based on the emergency plan, including lack of a plan to maintain emergency power systems operational during emergencies.
K0712: Fire drills were conducted between 9:00 PM and 6:00 AM without adequate communication systems between staff and floors.
K0918: The facility failed to maintain the essential electric system generator per NFPA 110, including lack of monthly testing records.
K0363: Corridor doors did not resist passage of smoke due to gaps greater than 1/2 inch or failure to latch properly.
K0133: The facility had a penetration missing firestopping material in the 2-hour separation wall between residential care and LTC facility.
KO222: Two second floor exit doors were key coded and required multiple releasing operations to exit, with unclear or missing posted codes.
K0225: The facility failed to provide handrails on both sides of the second floor exterior stairs.
K0291: Emergency light outside room 210 did not function when tested.
K0754: Trash receptacles were stored in corridors instead of rooms, violating fire safety code requirements.
K0761: Fire doors, including kitchen corridor door, had gaps at upper latch side and did not positively latch when closed, compromising fire resistance.
Inspection Report — Dec 1, 2025
Renewal
Date: Dec 1, 2025
Visit Reason
This report documents a Recertification Survey conducted from 12/1/25 through 12/4/25 to assess Coastal Manor's compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several federal regulations, including resident rights, self-determination, safe environment, baseline care planning, medication administration, activities, quality of care, infection control, and resident records. Multiple deficiencies were identified based on observations, interviews, and record reviews.
Deficiencies (16)
F0550: The facility failed to ensure the dignity of residents by allowing an uncovered urine filled catheter bag to be seen by passersby for 3 of 3 residents with urinary catheters.
F0561: The facility failed to ensure resident choice in meal preferences for 2 of 3 sampled residents, as evidenced by repeated serving of unwanted food items despite resident statements.
F0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance deficiencies such as exposed wood creating uncleanable surfaces and baseboard damage on 2 floors.
F0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for 1 of 4 sampled residents, lacking necessary instructions for effective person-centered care.
F0657: The facility failed to develop comprehensive care plans within 7 days after assessment and interdisciplinary team review for 1 of 4 residents, lacking documentation of required team participation and timely revisions.
F0677: The facility failed to provide a continuous resident-centered activities program for 1 of 4 residents, lacking interventions to support participation and mental stimulation.
F0684: The facility failed to follow a physician order for diabetes management and provide blood glucose monitoring for 1 of 1 resident reviewed, lacking evidence of insulin administration and glucose checks.
F0689: The facility failed to ensure the resident environment was free of accident hazards, including unsecured chemicals and improper storage of cleaning supplies observed during the survey.
F0693: The facility failed to ensure residents received adequate enteral nutrition and care for feeding tubes, including failure to check gastric tube placement and assess for complications for 1 resident.
F0695: The facility failed to provide adequate respiratory care and tracheostomy suctioning for 2 of 3 residents, including lack of proper equipment cleaning and infection prevention.
F0761: The facility failed to ensure proper labeling and storage of drugs and biologicals, including temperature documentation failures and lack of secure storage for controlled substances.
F0810: The facility failed to provide special eating equipment and utensils as directed by care plans and physician orders for 1 resident, resulting in missing adaptive cups and risk of aspiration.
F0812: The facility failed to meet food safety requirements, including improper food storage, unlabeled and undated food items, and failure to serve food in a sanitary manner on multiple survey days.
F0842: The facility failed to maintain resident-identifiable information confidentiality and complete medical records, including missing documentation for activities of daily living and care provided by certified nursing assistants.
F0880: The facility failed to establish and maintain an effective infection prevention and control program, including inadequate hand hygiene, improper handling of linens, and failure to maintain personal protective equipment during medication passes and wound care.
F0883: The facility failed to implement pneumococcal immunization policies and procedures, including failure to provide education and documentation for 1 of 5 sampled residents.
Report Facts
: 3
: 2
: 2
: 1
: 1
: 1
: 1
: 3
: 18
: 17
: 21
: 9
: 5
Inspection Report — Jan 23, 2025
Follow-Up
Date: Jan 23, 2025
Visit Reason
Follow-up survey conducted to verify correction of deficiencies cited during complaint survey #ME000047751 dated 12/10/24.
Complaint Details
Complaint survey #ME000047751 dated 12/10/24
Findings
Coastal Manor was found to be in compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities; no deficiencies were cited.
Report Facts
: Dec 10, 2024
Inspection Report — Oct 3, 2024
Follow-Up
Date: Oct 3, 2024
Visit Reason
On 10/3/24, an on-site visit was conducted as a revisit follow-up to the annual Long Term Care Survey completed on 8/14/24.
Findings
Coastal Manor was determined to be in compliance with 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities, with no deficiencies cited.
Inspection Report — Aug 12, 2024
Annual Inspection
Date: Aug 12, 2024
Visit Reason
The survey was conducted as part of the annual Long Term Care Survey Process and to investigate complaint #ME00048414 and facility reported incident (FRI) #ME00048439.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment on 2 of 2 units, and failed to ensure accuracy of assessments, develop comprehensive care plans, provide trauma-informed care, and meet nutritional adequacy requirements.
Deficiencies (6)
§483.10(i)(7): The facility failed to maintain a safe, clean, comfortable, and homelike environment on 2 of 2 units, including stained ceilings, damaged wallpaper, exposed heating elements, and missing non-slip grips.
§483.20(g): The facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately in the area of Active Diagnosis for 1 of 3 sampled residents with a diagnosis of PTSD.
§483.21(b)(3): The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with PTSD that included measurable objectives and trauma-informed interventions.
§483.25(m): The facility failed to provide trauma-informed care ensuring culturally competent care and accounting for residents' experiences and preferences to eliminate or mitigate triggers.
§483.60(c): The facility failed to follow menus for 3 of 3 days of the survey and failed to serve food at an appetizing temperature on 2 of 2 floors, resulting in residents receiving food that was not palatable or served timely.
§483.60(d): The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, as evidenced by cold meals and resident complaints.
Report Facts
: ME00048414
: ME00048439
: 3
: 3
: 1
: 3
: 2
Inspection Report — Aug 8, 2024
Follow-Up
Date: Aug 8, 2024
Visit Reason
Unannounced on-site visit conducted to follow up on deficiencies cited during a survey dated 6-3-24, related to facility reported incidents and a complaint.
Findings
Coastal Manor was found to be in compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities, with no deficiencies cited during this follow-up survey.
Report Facts
: ME00047470
: ME00047637
: ME00047648
Inspection Report — Jun 3, 2024
Follow-Up
Date: Jun 3, 2024
Visit Reason
Follow-up on deficiencies cited during a complaint investigation dated #ME00047024.
Findings
No regulatory deficiencies were identified as a result of the 6/3/24 follow-up survey.
Report Facts
: ME00047024
Inspection Report — Apr 10, 2024
Complaint Investigation
Date: Apr 10, 2024
Visit Reason
Coastal Manor was investigated due to a complaint regarding failure to meet minimum staffing ratios on 6 of 14 days reviewed.
Findings
Coastal Manor failed to meet minimum staffing ratios on 6 days due to staff call-outs and weather-related absences. Additionally, the facility had not updated its Facility Assessment since October 2022, and the Administrator missed multiple QAA committee meetings.
Deficiencies (3)
T22: Minimum Staffing Rule: Coastal Manor did not meet minimum staffing ratios on 6 of 14 days reviewed due to staff call-outs and inability to fill shifts.
F838: Facility Assessment: The facility had not reviewed or updated the Facility Assessment since October 2022, risking inadequate resource planning for resident care.
F868: QAA Committee: The Administrator was absent from multiple QAA/QAPI meetings between June 2023 and March 2024, impacting quality assurance processes.
Report Facts
: ME00047024
: 6
: Array
: 10/2022
: May 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Feb 1, 2024
Complaint Investigation
Date: Feb 1, 2024
Visit Reason
Investigation of complaints #ME00045421 and #ME00046075.
Findings
Coastal Manor was found to be in substantial compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00045421
: ME00046075
Inspection Report — Nov 14, 2023
Complaint Investigation
Date: Nov 14, 2023
Visit Reason
Federal Complaint Survey conducted on November 14, 2023, to investigate compliance with National Fire Protection Association 101 Life Safety Code.
Findings
Coastal Manor was found not in compliance with multiple fire safety requirements including aisle clearance, stairwell enclosure, fire alarm system testing, fire drills, soiled linen collection, door maintenance, electrical system testing, and emergency lighting. Deficiencies affected residents on multiple floors and involved safety hazards such as blocked exits, missing fire-rated tags, and failed emergency equipment.
Deficiencies (8)
K232: Aisle, Corridor, or Ramp Width - The width of aisles or corridors serving as exit access was less than 4 feet due to couch and chair stored in the 2nd floor exit corridor.
K311: Vertical Openings - The fire door protecting the center stairwell lacked a fire-rated tag and was equipped with residential hardware, compromising fire resistance.
K345: Fire Alarm System - Documentation was not provided to confirm that sensitivity testing of the smoke detection was completed within one year as required by NFPA 72.
K712: Fire Drills - The facility failed to conduct 3rd shift announced fire drills at varied times as required, with drills conducted at the same time and some missed in the first quarter of 2023.
K754: Soiled Linen and Trash Containers - The facility failed to maintain mobile soiled linen collection receptacles in a room protected as a hazard area, exceeding allowed container capacity and lacking proper location.
K761: Maintenance, Inspection & Testing - The facility failed to maintain 2-hour fire-rated doors free of holes and penetrations, with multiple holes located on the top latch side of a cross-corridor door.
K918: Electrical Systems - The facility failed to provide documentation for monthly inspection and testing of the emergency generator and transfer switches for the last 12 months.
K291: Emergency Lighting - Emergency light #3 outside the nurse's station was not operational when tested, affecting the first floor residents.
Report Facts
: 11:30 AM to 1:00 PM
: 6:35 AM
: 32 gallons
: 4
: monthly
Document — MMW622 SOD
Date: MMW622 SOD
Inspection Report — 0CK921 POC
Date: 0CK921 POC
Visit Reason
Federal Recertification Survey for Coastal Manor Nursing Home
Findings
The facility was surveyed pursuant to the National Fire Protection Association 101 Life Safety Code, 2012 Edition. Multiple deficiencies were cited related to emergency preparedness training, fire alarm system maintenance, exit access, and sprinkler system maintenance. Corrective actions and plans were documented.
Deficiencies (11)
E037: The long term care facility failed to provide Emergency Preparedness training annually in accordance with 42 CFR 483.73.
K133: The facility failed to maintain the clear locations of the 2-hour separation walls for inspection per NFPA 101, Life Safety Code, 2012 Edition, Sections 8.2.1.3, and 19.1.3.5.
K211: The facility failed to maintain the corridors and exit discharges to be level, free of obstructions and impediments, and without excessive changes in elevation per NFPA 101, Life Safety Code, 2012 edition, Sections 19.2, 7.1.6, and 7.1.10.1.
K222: The facility failed to provide exit access serving the every egress door that were readily accessible at all times by having special locking arrangements in accordance with LSC Section 19.2.2.2.4, 19.2.2.2.5, 19.2.2.2.6 and 7.2.1.6.
K341: The facility failed to ensure the proper notification devices were installed in the fire alarm system in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 9.6.1.3, 9.6.3.5, and 9.6.5.
K345: The facility failed to maintain the fire alarm system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, 2011 edition, sections 4.1.8, 5.2.1.4, 5.4.1.5, 5.4.1.6, 5.2.2.2.
K353: The facility failed to maintain the sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, 2011 edition, sections 9.6.1.3, 9.6.3.5, and 9.6.5.
K363: The facility failed to maintain corridor doors to resist the passage of smoke in 2 of 2 residential areas per NFPA 101, Life Safety Code, 2012 edition, Sections 19.3.6.3.
K918: The facility failed to perform weekly generator tests and inspections in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition, Section 8.4.1.
K919: The facility failed to maintain electrical equipment in accordance with NFPA 99, Chapter 10, Electrical Equipment requirements.
K923: The facility failed to maintain oxygen cylinder storage in accordance with NFPA 101, Life Safety Code, 2012 Edition, Sections 11.3.2 and 11.6.5.
Report Facts
: Aug 13, 2024
: Aug 13, 2024
: Aug 20, 2024
: Aug 23, 2024
: Array
Inspection Report — 1DB93A H1 POC
Plan of Correction
Date: 1DB93A H1 POC
Visit Reason
Facility submitted a Plan of Correction addressing multiple deficiencies cited in a prior survey.
Findings
This document is the facility's Plan of Correction for the survey dated January 30, 2026, addressing deficiencies related to resident rights, self-determination, environment, care planning, medication administration, ADL care, activities, quality of care, diabetes management, accident hazards, enteral nutrition, respiratory care, medication storage, assistive devices, food procurement, resident records, infection prevention, and immunizations.
Report Facts
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
: Jan 30, 2026
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