Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to ensure the menu was followed as
planned during lunch tray line (a system of food preparation in which trays move along an assembly line)
when 2 residents (Resident 18 and 32) small portion diet were not followed.
This failure had the potential not to meet the nutritional needs as planned to maintain normal body weight
and acceptable nutritional values of residents.
Findings:
During a concurrent observation with the Dietary Manager (DM) on 5/06/24 at 11:58 a.m., of the lunch meal
service in the kitchen steam table, part of the menu for the day (5/06/24),were cheesy mashed potatoes,
carrots,and turkey. For the cheesy mashed potatoes, the scoops prepared for meal serving were #8 scoop
(=1/2 cup) and a #16 scoop (=1/4 cup). For the diced and minced turkey, a 3-ounce spoodle was in place.
During a concurrent observation and interview on 5/06/24 at 12:19 p.m., with the [NAME] (CK), in the
kitchen, the meal cards for Residents 8 and 32 indicated ,small portion diet and 2 ounces of meat. CK was
noted using scoop #8 (1/2 cup) for the potatoes served on the meal plates of Residents 8 and 32, in
addition to 3 ounces of diced /minced turkey. When the meal carts were about to leave the kitchen, surveyor
asked the Dietary Manager (DM) to check the meal plates of Residents 8 and 32. The DM, confirmed the
meal plates of Residents 18 and 32, had 1/2 cup of mashed potatoes ( # 8 scoop), instead of 1/4 cup
mashed potatoes as ordered prepared by using scoop # 16 for small portion diet and 3 ounces of
diced/minced turkey.
During an interview on 5/06/24 at 12:23p.m., with the CK, and with the DM translating the questions, CK
stated, not being aware the scoop used for Residents 8 and 32 , for the small portion diet was #8 scoop ,
instead of scoop #16. Both residnets were also served 3 ounces of diced /minced turkey , instead of just 2
ounces as ordered. This was verified by CK, upon checking of the meal spreadsheet .
During a review of the facility's DCC (Danish Care Center) Spring/Summer 2024 Diet Spreadsheet menu,
dated 5/03/24, showed three ounces of roasted thyme turkey, 1/2 cup of cheesy potatoes, 1/2 cup (#8
scoop) sliced carrots for the regular diet, small bite size (SB6) diet and minced and moist (MM5) diet. It
showed under the small portion diet 2 ounces roasted thyme turkey and 1/4 cup cheesy potatoes.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
555554
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555554
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coastal Oaks Special Care Center
10805 El Camino Real
Atascadero, CA 93422
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record review and interview, the facility failed to maintain medical records for three of 3 sampled
residents (Resident 46, 38 and 44) and for one unsampled resident (Resident 47) were in accordance with
professional standards and practices when:
1). Resident 46, physician ordered supplement intakes were not documented in the medical record.
2). Resident 38, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage ((SNFABN) notice of
Medicare coverage ending) signature of resident representative was not legible or identified.
3) . Resident 44, Resident-Facility Arbitration Agreement ((RFAA) opting for a private dispute resolution
procedure instead of going to court agreement) signature of resident representative was not legible or
identified.
4). Resident 47, SNFABN date of notification was omitted.
These failures had the potential to eflect a resident's progress towards achieving their person-centered plan
of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and
psychosocial status
Findings:
During a review of the facility's policy and procedure (P&P) titled, Resident Records-Identifiable
Information, Clinical Records, no date, the P&P indicated, Clinical records are complete, accurately
documented, readily accessible and systematically organized.
1) During a review of Resident 46's May 2024 Physician Order Sheet, dated 4/01/2024, the Physician Order
Sheet indicated Resident 46 to have house supplement (120cc) oral BID (twice a day) at lunch and dinner.
During a review of Resident 46's ADL [activity of daily living] Verification Worksheet, date range 4/01/24
through 5/08/24, the ADL Verification Worksheet had only nine days with recorded intakes by the Certified
Nursing Assistant (CNA).
During a review of the facility's policy and procedure (P&P) titled, High Calorie/High Protein Supplements,
dated 2022, the P&P indicated, Nursing staff will supervise the delivery and consumption of all
supplements and record appropriately in the medical record, meal intake reporting records, and/or the
medication administration record.
During an interview on 05/08/24 11:49 a.m. with CNA1, CNA1 stated I have worked here almost 5 years, in
charge of documenting breakfast, lunch and dinner, when we document the meal there is a section for
supplements like the mighty shake. It is always the CNAs that document the meals.
During an interview on 05/08/24 11:55 a.m. with the Director of Staff Development (DSD), DSD stated, after
each meal the CNAs will document meals and supplements, supplements yes or no, then it will ask how
much, the CNA will write the point system like the percentage, CNA training would be done on initial hire,
chart audits, on the tray card will verify that it is on the meal ticket, or if they
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555554
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555554
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coastal Oaks Special Care Center
10805 El Camino Real
Atascadero, CA 93422
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
refused the supplement. I have a handout but not a policy.
Level of Harm - Minimal harm
or potential for actual harm
2) During a review of Resident 38's SNFABN, dated 2/6/24, the SNFABN indicated, Signature of Patient or
Authorized Representative, signature was illegible and without identification for the signature.
Residents Affected - Few
During an interview on 5/8/24 at 10:50 a.m. with the Administrator (ADM), ADM reviewed the SNFABN and
stated, the resident representative signature was illegible and should have been identified.
3) During a review of Resident 44's RFAA, dated 11/21/22, the RFAA indicated, Resident
Representative/Agent Signature, signature was illegible and without identification for the signature.
During an interview on 5/8/24 at 10;50 a.m. with ADM, ADM reviewed the RFAA and stated, the resident
representative signature was illegible and should have been identified.
4) During a review of Resident 47's SNFABN, dated 2/6/24, the SNFABN indicated, Date, without a date.
During an interview on 5/8/24 at 10:50 a.m. ADM, ADM reviewed the SNFABN and stated, the date the
phone call was made should have been documented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555554
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555554
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coastal Oaks Special Care Center
10805 El Camino Real
Atascadero, CA 93422
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0848
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure three of three sampled residents
(Resident 22, 44, and 46) binding arbitration agreements had clearly stated the selection of a neutral
arbitrator agreed upon by both facility and resident or resident representative and clearly stated the
selection of a venue that is convenient to both facility and resident or resident representative.
Residents Affected - Few
This failure had the potential to result in psychosocial harm in the event of an arbitration dispute.
Findings:
During a review of:
Resident 22's RESIDENT-FACILITY ARBITRATION AGGREEMENT (RFAA), dated 7/8/21, the RFAA did
not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident
representative and did not indicate the selection of a venue that is convenient to both facility and resident or
resident representative.
Resident 44's RFAA, dated 11/21/22, the RFAA did not indicate the selection of a neutral arbitrator agreed
upon by both facility and resident or resident representative and did not indicate the selection of a venue
that is convenient to both facility and resident or resident representative.
Resident 46's RFAA, dated 4/7/23, the RFAA did not indicate the selection of a neutral arbitrator agreed
upon by both facility and resident or resident representative and did not indicate the selection of a venue
that is convenient to both facility and resident or resident representative.
During an interview on 5/8/24 at 3 p.m., with the Administrator (ADM), ADM stated the required verbiage is
not there.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555554
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555554
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coastal Oaks Special Care Center
10805 El Camino Real
Atascadero, CA 93422
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to maintain essential equipment and
safe operating condition, when the refrigerator gasket was found to have been torn.
Residents Affected - Few
This failure resulted in the door not being able to seal appropriately and with potential to effect food
temperatures.
Findings:
During a concurrent observation and interview on 05/08/24 at 02:46 p.m. of the snack shack refrigerator,
the low-fat milk in the door was 48 fahrenheit (The standard scale used to measure temperature in the
United States) when measured with the facility thermometer and verified by the Dietary Manager (DM) .
The DM stated they took measurements to get a new refrigerator ordered. The DM Stated if they had seen
the torn gasket then they would have notified maintenance about it for repair.
During an interview and observation on 05/08/24 at 03:54 p.m. of the snack shack refrigerator, Facilities
Manager (FM) stated he was not aware about the tear in the gasket. FM stated he would expect to be
notified of this needing to be replaced by staff or in the maintenance logbook.
During a review of the Maintenance Repair Log, dated 7/25/23 through 5/7/24, the Maintenance Repair Log
did not indicate any reporting of the torn gasket for the snack shack refrigerator.
During a review of the facility's policy and procedure (P&P) titled, Maintenance Preventative Maintenance
Program, undated indicated, These goals are accomplished by detecting and correcting minor defects
before they develop into serious problems and by performing the services necessary to prevent undue wear
and subsequent breakdown.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555554
If continuation sheet
Page 5 of 5
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F848 - Arbitrator/Venue Selection and Retention of Agreements
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the May 10, 2024 survey of Coastal Oaks Special Care Center?
This was a inspection survey of Coastal Oaks Special Care Center on May 10, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Coastal Oaks Special Care Center on May 10, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.