Marine Creek Nursing & Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one (Resident #1) of six residents reviewed for the storage of drugs and biologicals. This facility failed to ensure MA A did not leave Resident #1's medications unattended on the Medication Cart located on the 400 hall, while she was in another resident's room. This deficient practice had the potential risk of affecting all residents who received medications on the 400 hall, which could cause residents to miss getting their medications or cause other residents to ingest the medications, which could result in adverse reactions in residents.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of ten residents (Resident #1) reviewed for medically related social services. The facility failed to ensure a Social Worker assisted Resident #1that was under the age of 22, in obtaining additional resources and services related permanency. This failure could place all residents at risk of not having their needs and preferences met according to permanency planning regulations for those under the age of 22. Record Review of Resident #1's face sheet dated 12/31/2025, reflected she was [AGE] years old, admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as is possible for 2 of 4 hallways reviewed. The facility failed to ensure 2 of 4 assisted lifting devices were secured properly while being stored in 2 of 4 hallways. This failure had the potential to cause harm to the residents by creating avoidable accident hazards.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews, the facility failed to protect residents' right to a safe, clean, comfortable and homelike environment for 20 of 31 residents in the secured unit reviewed for resident rights. The male side of the secured unit had a strong urine smell on 9/16, 9/17 and 9/18/2025. This failure could result in lack of residents' hygiene and could affect their dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents resided and received services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #136 and Resident #112) of thirty-eight residents reviewed for call lights. Staff failed to ensure Resident # 136's and Resident # 112's call buttons were within reach. This failure could place residents at risk for needs not being met, decreased quality of life, self-worth and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #28) of thirty-eight residents reviewed for supervision and ensured the environment remained free of accident hazards. The facility failed to ensure Resident #28 was not in possession of over-the-counter isopropyl alcohol located in resident's room. These failures could place residents at risk of being in danger and could be fatal if a resident ingested isopropyl alcohol.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 2 (Resident #45 and Resident #23) of 2 residents reviewed for abuse, in that: On 08/29/2025, the facility failed to ensure that Resident #45 was not punched in the face by Resident #23, resulting in injury to the face. This failure resulted in injuries to Resident #45. Resident #45Record review of a face sheet dated 09/03/2025 revealed Resident #45 was [AGE] years old and was admitted on [DATE] with a primary diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, and other pertinent diagnoses including cognitive communication deficit and mood disorder due to known physiological condition with major depressive-like episode. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fourteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of thirty residents reviewed for privacy and confidentiality. 1. The facility failed to ensure LVN C pulled the privacy curtain while suctioning (mechanical aspiration of pulmonary secretions to clear the airway) Resident #1 on 07/12/2025. 2. The facility failed to ensure LVN C closed the door while suctioning Resident #2 on 07/12/2025. 3. The facility failed to ensure LVN D did not leave Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13's medical information on top of his cart on 07/12/2025. 4. [...]

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #1, Resident #2, Resident #12 and Resident #15) of twenty residents reviewed for infection control. 1. The facility failed to ensure LVN C did not re-use a gown to provide treatment for some residents at hall 400 on 07/12/2025. 2. The facility failed to ensure LVN C changed her gown in between Resident #1 and Resident #2 who were with tracheostomy on 07/12/2025. 3. The facility failed to ensure LVN C changed her gloves and performed hand hygiene when changing Resident #2's tracheostomy dressing on 07/12/2025. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #12) of five residents reviewed for feeding tube (a process of providing nutrition directly to the stomach). The facility failed to ensure LVN C checked Resident #12's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering the resident's medications and failed to administer the resident's medication one by one on 07/12/2025. These failures could place residents with g-tubes at risk for aspiration and drug-to-drug interaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 2 of 3 (Emergency cart 1, Emergency cart 2) emergency crush carts reviewed for emergency preparedness. 1. Facility failed to have an ambu bag [is a portable, handheld device used to provide ventilation to a resident struggling to breathe or has stopped breathing] on Emergency cart 1. 2. Facility failed to check inventory daily on Emergency cart 2 from [DATE] to [DATE] and from 4/20 to [DATE]. These failures could place residents at risk for delayed emergency care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24. This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. Findings Included: [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure RN A was trained on using a non-rebreather on Resident #1 and what parameters are required and when to discontinue use of the non-rebreather. This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. Findings Included: Record review of Resident #1 ' s admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #1) reviewed for enteral nutrition. The facility failed to ensure the date and time was written on Resident #1's formula and water bag . This failure could place residents at risk of malnutrition and dehydration.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #1) of five residents reviewed for personal property. The Administrator took Resident #1's cell phone away from her because she had called 911 several times. This failure could place residents at risk of not being able to retain and use personal property.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from verbal abuse for 1 of 1 resident reviewed for mistreatment, (Resident #1). The facility did not prevent CNA B from mistreating Resident #1. CNA B yelled at Resident #1 during the early morning of 10/31/2024 trying to force resident to go to bed causing Resident #1 to become angry. This failure could place residents at risk for staff mistreatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as is possible for 1 of 6 residents (Resident #2) reviewed for environmental hazards. The facility failed to ensure Resident #2's bedframe and mattress were maintained to prevent accidents. This failure could place residents at risk of accidents and injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 facility reviewed for effective pest control. 1. The facility failed to effectively treat for flies. 2. The facility failed to effectively treat for roaches. These failures could place all residents at risk for the potential of a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 7 residents reviewed for respiratory care (Residents #5 and #16). 1. RN K staff failed to ensure Resident #5's and Resident #16's nasal cannula was bagged for sanitation when not in use per the facility's policy on 10/09/24. 2. RN K failed to ensure Resident #5's oxygen concentrator and filter were free of food crumbs, debris (dust gray fuzzy participles) and spilled brown liquid on 10/09/24. 3. RN K failed to ensure Resident #16's nasal cannula was bagged for sanitation when not in use per the facility's policy on 10/09/24. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy for 1 of 5 residents (Resident #1) reviewed for personal privacy. LVN P failed to ensure Resident #1's dignity and privacy was provided when he failed to use the privacy curtain as she laid naked and exposed. This failure placed the residents at risk of not having their privacy respected.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents in need of ADL care the necessary services to maintain good personal hygiene for 1 of 30 residents (Resident #33) reviewed for showers. The facility failed to ensure Resident #33 received showers/baths on scheduled days. This failure could affect residents by putting them at risk for diminished quality of life, hygiene, and self-esteem.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #106) reviewed for resident records. Facility failed to ensure physician orders were written for ventilator setting for Resident #106 on admission [DATE] to 08-22-2024. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #18, #59, #72, and Resident #437) of 12 residents reviewed for infection control. The facility failed to ensure LVN M disinfected blood sugar monitoring device between use on Resident #18, #59, and Resident #437 and failed to ensure LVN M performed hand hygiene after removing gloves and touching contaminated blood sugar monitoring device between use on Resident #18, #59 and Resident 437. The facility failed to ensure RN G put on PPE for EBP and perform hand hygiene when administering G-tube medication to Resident #72. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 30 residents (Residents #66, 42, and #103) reviewed for effective pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of flies for Resident #66, #42, and #103 in the facilities only dining room. This failure could place the residents at risk for an unsanitary environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 of 30 (Residents #17 and #114) reviewed for accommodation in needs. The facility failed to ensure Resident #17 and #114's call lights were within reach of the resident. This failure could have affected residents who needed assistance and could have resulted in their needs not being met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for one of five residents (Resident #18) reviewed for privacy. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of their EHR as evidenced by record review for Resident #18. This failure could place residents at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #487) of twelve resident reviewed for enteral feeding. The facility failed to ensure Resident #487's G-tube water and enteral administration set (tubing attached to formula and water bottles for continuous G-tube feeding) were changed when his formula was changed on 08-19-2024 and on 08-21-2024 and failed to ensure the water was dated when it was changed. This failure could place residents at risk of infection due to not following appropriate procedures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for one (Resident #487) of 2 residents reviewed for intravenous fluids. The facility failed to ensure Resident #487 received PICC line orders to manage, access, flush, and perform dressing changes since admission [DATE]. A Peripherally Inserted Central Catheter -PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy, giving fluids, and or getting clinical nutrients. This failure could place residents at risk for infection. Review of Resident #487's face sheet dated 08-21-2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two of three medication carts and one of one respiratory treatment carts reviewed for medication storage The facility failed to ensure two (Medication Cart#1 and Medication Cart#2) facility medication cart and one (RTC) respiratory treatment cart were locked when unattended on 08/14/24. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure before a facility transfers or dischargers a resident the facility must send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of eight residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged to hospital on [DATE]. This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 residents (Resident #1) reviewed for transfers: The facility failed to provide Resident #1 with a written bed-hold policy when the resident was transferred out to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred; at risk for of being improperly discharged and placed in unsafe conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice for one (Resident #1) of eight residents reviewed for tracheostomy care. The facility failed to use the recommended amount of pressure (maximum of 25 cmH2O) per manufacturer to inflate Resident #1's tracheostomy tube cuff, which led to chronic over inflation and caused remodeling of the residents T1 and T2 vertebra and swallowing difficulty that likely caused starvation ketoacidosis (metabolic state after prolonged deprivation of glucose as primary source of energy). An Immediate Jeopardy (IJ) was identified on 06/27/24. An IJ Template was provided to the facility on [DATE] at 3:30 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care for 4 of 5 resident's (Resident #1, Resident #3, Resident #5, and Resident #7) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's oxygen tubing was dated, and his CPAP mask and portable nasal cannula on his wheelchair were bagged and dated when not in use. 2. Resident #3, #5, and #7's oxygen tubes were not labeled, stored, and changed for resident. These failures affected resident's and placed them at risk of not receiving the needed services for respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected behaviors of not using the call light when he needed assistance, removing his CPAP mask, and throwing both to the floor when agitated. This deficient practice could place residents at risk of not receiving appropriate care and interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 6 residents (Resident #1) reviewed for resident call system, in that. Resident #1s call lights was on the floor and not within reach. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 residents (Residents #1) reviewed for abuse and neglect. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 of 3 residents (Residents #1) reviewed for supervision. The facility failed to ensure Resident #1, who had severe cognitive impairment and resided on the secure unit, received adequate supervision to prevent her from wandering into the facility's enclosed courtyard without staff knowledge and being left outside for approximately 3 hours while it was raining. The facility failed to ensure the door that led to the enclosed courtyard was locked or supervised, when the door's locking mechanism lost power during the storm. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 04/01/24 and ended on 04/02/24. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one, based on the resident's comprehensive assessment, receives appropriate treatment and services for 1 of 1 resident (Resident #1) reviewed for incontinence. The facility failed to ensure: Resident #1's catheter bag was placed below the level of the bladder and remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) on 11/16/23. Resident #1 had a catheter strap and was held in place to prevent pulling or tugging of indwelling catheter tubing at insert site on 11/16/23. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 2 of 5 residents (Residents #1 and #3) reviewed for quality of care. The facility failed to provide wound care services for Resident #1 as ordered on 11/03/23, 11/06/23, 11/08/23, 11/11/23 (night), 11/12/23 (night), and 11/13/23 (evening and night). The facility failed to provide wound care services for Resident #3 as ordered on 11/06/23 and 11/08/23. This failure could place residents at risk of infection and/or deterioration of their wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for 1 of 5 residents (Resident #2) reviewed for wound care. The facility failed to provide wound care services for Resident #2 as ordered on 11/03/23, 11/06/23, and 11/08/23. This failure could place residents at risk of infection and/or deterioration of their pressure ulcers. Resident #2: Record review of Resident #2's electronic Facesheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure orders were provided for the resident's immediate care and needs for 1 of 1 resident (Resident #1) reviewed. LVN B failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for Mupirocin cream applied topically to Resident #1. This failure had the potential to place Resident #1 at risk of an adverse drug reaction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 7 (Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62) of 114 residents reviewed for call lights. The facility failed to ensure Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62's call buttons were within reach. This failure could place residents at risk for decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 23 residents (Resident #97) reviewed for ADLs. The facility failed to provide Resident # 97 with showers/bed baths on a consistent basis. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status.