Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with the facility's Transfer and Discharge policies, specifically regarding notification requirements to residents, responsible parties, and the Long-Term Care Ombudsman office.
Findings
The facility failed to notify Resident #1 and responsible parties in writing of the discharge and transfer details, omitted required information such as the date, reason, location, appeal rights, and Ombudsman contact information, and did not provide a copy of the discharge notice to the local Ombudsman office.
Deficiencies (1)
Failure to provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Report Facts
Resident Medicare days exhausted: 100
Admission date: Jun 21, 2025
Discharge date: Jul 20, 2025
BIMS score: 15
Resident weight: 162
Resident height: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding discharge notices and procedures. |
| Director of Nursing | Director of Nursing | Interviewed regarding discharge planning and care plans. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as an annual survey of Coastal Health and Rehabilitation Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 14, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an alleged neglect incident involving Resident #2 who eloped from the facility without proper notification to the State Survey Agency.
Complaint Details
The complaint investigation revealed that Resident #2 eloped from the facility on 4/28/2024 without the facility reporting the incident to the State Survey Agency as required. The resident lacked decisional capacity and was discharged early against medical advice. The facility did not submit any federal or adverse incident reports related to this event.
Findings
The facility failed to report the elopement of Resident #2 within 24 hours as required. Resident #2 left the facility against medical advice by exiting through a window and was found at home. The facility did not file the required federal or adverse incident reports. Interviews with staff and review of records confirmed the incident and lack of reporting.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to Resident #2's elopement.
Report Facts
Date of elopement: Apr 28, 2024
Date of survey completion: Jun 14, 2024
Mini mental status exam score: 10
Time of elopement notification: 137
Time of ARNP call to DON: 228
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Licensed Practical Nurse (LPN) | Accompanied DON on wellness check at Resident #2's home and provided details on elopement |
| Employee B | Receptionist | Provided information on elopement procedures and training during interview |
| Employee C | Certified Nursing Assistant | Present during interview with Employee B |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding Resident #2's elopement and actions taken |
| Administrator | Administrator | Interviewed and confirmed failure to report elopement and described tracking responsibilities |
Inspection Report
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a comprehensive person-centered care plan addressing the sexual relationship of two residents.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan that addressed the sexual relationship for two residents. Both residents were cognitively intact and capable of consenting to a sexual relationship, but their care plans did not include goals or interventions related to their relationship despite staff awareness.
Deficiencies (1)
Failed to develop and implement a comprehensive person-centered care plan addressing the sexual relationship for two residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named as part of the interdisciplinary team that deemed residents capable of consenting to a sexual relationship and involved in confirming care plan status. | |
| Administrator | Interviewed regarding care planning for residents' sexual relationship. |
Inspection Report
Deficiencies: 5
Date: May 18, 2023
Visit Reason
The inspection was conducted based on observations, resident and staff interviews, complaint investigations, and medical record reviews to assess compliance with resident rights, medication monitoring, PASRR submissions, skin impairment documentation, and hospice services coordination.
Findings
The facility was found deficient in multiple areas including failure to ensure staff knocked before entering resident rooms, failure to update and resubmit PASRR for a resident with new diagnoses, failure to monitor behaviors and side effects for residents on psychotropic medications, failure to maintain accurate medical records for skin impairments, and failure to properly coordinate hospice services including documentation and designation of a hospice coordinator.
Deficiencies (5)
Failed to ensure staff knocked and asked permission before entering six resident rooms and prevent one resident from posting another resident's name on a stop sign in full view of others.
Failed to update and resubmit a Preadmission Screening and Resident Review (PASRR) for one resident after new diagnoses were added.
Failed to ensure pharmacy consultant reported irregularities and that behavior and side effect monitoring were documented for one resident receiving psychotropic medications.
Failed to maintain accurate medical records documenting significant bruising on a resident's hand.
Failed to ensure hospice residents had evidence of medical record communication with hospice providers, signed contracts, and a designated hospice coordinator.
Report Facts
Residents affected: 6
Residents affected: 5
Residents affected: 1
Residents affected: 8
Residents in sample: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PCA F | Personal Care Attendant | Named in deficiency for entering rooms without knocking |
| Registered Nurse Supervisor | RNS | Responsible for PCA training and interviewed about privacy training |
| Licensed Practical Nurse G | LPN | Interviewed regarding resident wandering and privacy concerns |
| Certified Nursing Assistant H | CNA | Interviewed about resident wandering and privacy concerns |
| Certified Nursing Assistant I | CNA | Interviewed about resident wandering and privacy concerns |
| Social Services Director | SSD | Interviewed about resident complaints and hospice coordination |
| Director of Nursing | DON | Interviewed about PASRR, medication monitoring, skin impairment documentation, and hospice coordination |
| Licensed Practical Nurse A | LPN | Interviewed about behavior monitoring documentation |
| Registered Pharmacist Consultant | RPh | Interviewed about pharmacy consultant responsibilities and medication monitoring |
| Licensed Practical Nurse G | LPN | Interviewed about skin impairment documentation |
| Certified Nursing Assistant C | CNA | Interviewed about hospice provider visits and documentation |
| Registered Nurse/MDS Coordinator D | RN | Interviewed about hospice provider communication |
| Licensed Practical Nurse E | LPN | Interviewed about hospice provider communication |
| RN Case Manager | RN | Interviewed about hospice provider communication and documentation |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 10, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food safety, and facility systems such as call systems.
Findings
The facility was found deficient in multiple areas including failure to implement care plan interventions for oxygen use, administering oxygen without physician orders, improper medication labeling and administration practices, failure to monitor psychotropic medication side effects, unsafe food storage and handling practices, and non-functioning resident call systems in bathrooms and bathing areas.
Deficiencies (6)
Failed to implement care plan interventions for oxygen use for Resident #197.
Failed to ensure physician's orders for oxygen use for Residents #59, #62, and #85 and failed to administer oxygen at ordered flow rate for Resident #197.
Failed to monitor resident behaviors and potential side effects related to psychotropic medication for Resident #85.
Failed to ensure medications were properly labeled and administered safely for Residents #78 and #79.
Failed to store, prepare, distribute and serve food in accordance with professional standards, including unlabeled and undated food items and unsafe thawing practices.
Failed to ensure the resident call system was functioning for Residents #28 and #75.
Report Facts
Residents reviewed for oxygen use: 42
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication administration observation: 6
Residents reviewed for call system functioning: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee K | RN | Interviewed regarding oxygen flow rate instructions and care plan for Resident #197 |
| Employee I | LPN | Interviewed regarding oxygen orders and administration for Resident #59 |
| Employee F | Certified Nursing Assistant (CNA) | Interviewed regarding oxygen use for Resident #62 |
| Employee G | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #62's oxygen use and orders |
| Employee C | Registered Nurse (RN) | Observed and interviewed regarding oxygen use for Resident #85 and medication administration for Residents #78 and #79 |
| North wing Unit Manager | Interviewed regarding oxygen orders, flow rates, and psychotropic medication monitoring | |
| Director of Nursing | Interviewed regarding medication administration practices | |
| Employee B | RN Unit Manager | Interviewed regarding non-functioning call system for Residents #28 and #75 |
| Employee A | RN | Interviewed regarding non-functioning call system for Residents #28 and #75 |
| Maintenance Director | Interviewed regarding call system checks and issues with moisture causing system failure | |
| Certified Dietary Manager (CDM) | Observed and interviewed regarding food storage and labeling deficiencies |
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