Martin Coast Center for Rehabilitation and Healthc

Inspectors wroteBased on record reviews and interviews, the facility failed to act promptly upon grievances voiced at resident council meetings for 5 residents (Resident #116, #54, #52, #10, #48) of 11 sampled residents, who attended the Resident Council Meeting held during the survey, and for 1 resident (Resident #28) who complained during the initial screening process.

Inspectors wroteBased on policy review, interview, and record review, the facility failed to ensure timely right to self-administer medications with the interdisciplinary team (IDT) assessment for 2 of 5 sampled residents reviewed for choices (Resident #104 and #7).

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure they provided a safe, clean, homelike environment for 7 of 13 rooms on the 300 unit (Rooms 306, 307, 311, 312, 313, 314, and 315)

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide nail care for 1 of 2 sampled residents (Resident #21), who was reviewed for nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively communicate and document communication with medical professionals for 1 of 5 sampled residents observed during the medication administration observation. Resident #126 had low blood pressure readings on two consecutive days and Staff E, Registered Nurse (RN) made independent decisions as to which blood pressure medications to hold and then later provide. The facility also failed to ensure accurate skin assessments for 1 of 14 new admissions as evidenced by the failure to include a skin impairment to the right leg of Resident #126.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to identify and treat hand contractures for 1 of 2 sampled residents, Resident #94, reviewed for range of motion.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure tracheostomy care was performed and documented; and failure to ensure of emergency equipment at bedside for residents with tracheostomy for 1 of 1 sampled resident reviewed for tracheostomy (Resident #7).

Inspectors wroteBased on observations, record review and interview, the facility failed to remove bed rails for residents that were assessed not to have them (Resident #69 and Resident #78); and failed to get obtain appropriate assessments for a resident was able to have bedrails (Resident #11) for 3 of 3 residents renewed for bedrails. 1. Review of Resident #11 medical records revealed the resident was admitted to the facility 12/19/22 with a diagnosis to include Dementia with Psychotic Disturbances, Anxiety Disorder, Parkinson's Disease, and Wandering. Her quarterly Minimum Data Set (MDS) assessment documents her Brief Interview for Mental Status (BIMS) was 00, indicating severe cognitive impairment. During multiple observations from 04/09/26-04/09/26, the resident was seen with side rails / enablers up on her bed. Review of the physician orders, dated 03/19/26, documented for side rails. [...]

Inspectors wroteBased on observations interview and record review the facility failed to follow their policy to assure the drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 8 sampled residents reviewed for medication reconciliation (Resident #20 and #50).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide the minced and moist diet to 3 of 3 sampled residents (Resident #77, Resident #132, and Resident #3). This had the potential to affect 9 residents who were on the minced and moist diet.

Inspectors wroteBased on record review and interview the facility failed to ensure offering and provision of the pneumococcal vaccine for 1 of 5 sampled residents, Resident #48.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow the approved menu for lunch on 11/06/24, and failed to notify the residents of the change in the menu.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide meals prepared, served and stored in a sanitary manner in accordance with standards for food safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to speak in a dignified manner during care, activities, and meals for 4 of 4 sampled residents (Resident #36, #86, #8, and #83), reviewed for dignity

Inspectors wroteBased on interviews and record reviews, the facility failed to provide showers per resident's preferences and according to the shower schedule for 1 of 2 sampled residents reviewed for choices, (Resident #309).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services as a means to provide a clean, safe, and home like environment on 3 of 4 units, in the Shower room and the outside patio.

Inspectors wroteBased on interview and record review, the facility failed to ensure the participation of the resident in the development of the resident's care plan and ongoing participation in resident care planning meetings for 1 of 2 sampled residents reviewed for Care Planning (Resident #34).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with grooming, including hair washing and nail care to 3 of 5 sampled residents, who were dependent upon staff for care (Resident #28, #40, and #44).

Inspectors wroteBased on observation, record review, interview, and policy review, facility staff failed to assess lung sounds and vital signs pre and post nebulizer treatments for 3 of 3 sampled residents reviewed for nebulizer treatments (Residents #42, 95 and #63).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pain management for 1 of 5 sampled residents, as evidenced by the failure to administer a lidocaine patch, as per physician order for Resident #99.

Inspectors wroteBased on interviews and record review, the facility failed to ensure sufficient and appropriate social services are provided to meet the needs of 1 of 1 sampled resident (Resident #34), related to the following: 1) Advocating for resident and assisting in the assertion of their rights within the facility; 2) Assisting resident in voicing and obtaining resolutions to grievances about discharge wishes; 3) Assisting resident with financial and legal matters (e.g., referrals to lawyers); and 4) Assisting with transitions of care services (e.g., assisting the resident with identifying community placement options and completion of the application process, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure appropriate use of Personal Protective Equipment (PPE) during the use of a tracheostomy (artificial opening in the neck) and percutaneous endoscopic gastrostomy (PEG/surgical placement of a feeding tube) use for 1 of 1 sampled resident (Resident #95); and failed ensure timely contact isolation for 1 of 1 sampled resident (Resident #57).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide an appropriate mattress for 1 of 26 sampled residents (Resident #309).

Inspectors wroteBased on record review and interview, the facility failed to develop a protocol for the release of medical records requested on behalf of the resident's legal representative, failed to verify if the request was legitimate; and failed to release the resident's records for 1 of 2 sampled residents (Resident #1).

Inspectors wroteBased on record review, policy review, and interview, it was determined, the nursing staff failed to accurately document wound care treatment orders and the provision of wound care for 2 of 2 sampled residents (Resident #1 and #4).

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, serve and store foods under sanitary conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, safe, clean, comfortable home like environment, and failed to ensure comfortable water temperatures for bed baths and showers.

Inspectors wroteBased on interview, record review, grievance review, and policy review, the facility failed to report 2 of 2 credible allegations of misappropriation of property to the State Agency and Law Enforcement, affecting 2 of 2 sampled residents (Resident #51 and #76).

Inspectors wroteBased on interview, record review, grievance review, and policy review, the facility failed to investigate 1 of 2 credible allegations of misappropriation of property affecting 1 of 2 sampled residents (Resident #76).

Inspectors wroteBased on observations, interview and record review, the facility failed to complete a Level II PASSAR (Preadmission Screening and Resident Review) for 1 of 1 sampled residents reviewed, as required according to the information documented on the resident's Level I PASSAR Screening (Resident #54).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure appropriate care and services were provided for 1 of 1 sampled residents with an indwelling urinary catheter, (Resident #106) who was diagnosed with two urinary tract infections (UTIs), while residing at the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to reassess and implement nutritional interventions in a timely manner after a significant weight loss and continued decline for 1 of 6 sampled residents reviewed for weight loss (Resident #54).

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete record for 1 of 6 sampled residents reviewed for nutrition. Specifically, Resident #55 had a nurse witnessed concern with a subsequent referral to therapy, and the record lacked any documentation of the event or follow through.

Inspectors wroteBased on observation, interview, review of Quality Assessment and Assurance (QA&A) meeting sign-in sheets, and QA&A Committee Membership, the QA&A committee failed to ensure documented evidence of the participation of 2 of 3 mandated members of the committee, were in attendance at their monthly meetings (the Medical Director and Administrator or other individual in a leadership role).