Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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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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