Martine Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interviews during an abbreviated survey (2738206) the facility did not ensure that the Minimum Data Set accurately reflected the resident status for one (1) of three (3) residents (Resident #1) reviewed for general skin issues. Specifically, Resident #1 was admitted to the facility on [DATE] and the admission Minimum Data Set staged a wound on the sacrum as stage 2 (two) because it referenced the admission nurse's assessment. On 12/09/2025 the wound care provider assessed the wound as an unstageable wound, but the Minimum Data Set did not reflect this update. The 01/21/2026 Minimum Data Set has the sacral wound as a stage 4 (four). The policy titled MDS 3.0 last revised 8/2019, documented that the MDS 3.0 information will be completed by the Interdisciplinary Team (IDT). [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (2738206) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed for general skin issues. Specifically, Resident #1 was admitted to the facility on [DATE] with three (3) different wounds in separate locations, the wound on their sacrum was assessed by the admission nurse as a stage two (2) pressure ulcer, but there were no orders in the electronic medical record for care or treatment until 12/12/2025. The policy titled Skin and Pressure Injury Prevention last reviewed 6/2024 documented that the purpose of the procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey from 01/05/2026 to 01/12/2026, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, the kitchen refrigerators, freezers, spice/seasoning areas and dry storage areas contained food items that were expired, not labeled or dated with opened/prepared/expiration dates.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure the resident's right to be treated with dignity and respect. This was evident for one (Resident #206) of five residents reviewed for Dignity. Specifically, Resident #206 was placed in common areas of the unit while wearing a hospital gown.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure each resident with a mental disorder was evaluated and received care and services in the most integrated setting appropriate to their needs for one (Resident #85) of three residents reviewed for Preadmission Screening and Resident Review. Specifically, Resident #85 was not referred for Level II specialized services once their facility stay was no longer brief or finite.

Inspectors wroteBased on observations, record review and interviews the facility did not ensure each resident received treatment and care in accordance with the professional standards of practice and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #108) reviewed for Skin Conditions. Specifically, 1.) wound care was not provided as per physician order for Resident #108. In addition, Licensed Practical Nurse #1 documented 01/05/2026 through 01/07/2026 administration of wound care that was not provided.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey and Abbreviated survey (#2638932) on 01/05/2026 to 01/12/2026, the facility did not ensure the necessary treatment and services to promote healing and/or prevent new ulcers from developing for 3 of 3 residents (Resident #12, #8 and #169) reviewed for Pressure Ulcers. Specifically, for Resident # 12 with a left buttock stage two pressure ulcer, calcium alginate was not applied as per physician order, 2) for Resident #8 assessed at risk for pressure ulcers, heel offloading was not implemented as per care plan, and 3) for Resident #169 assessed at risk for pressure ulcers, heel offloading was not implemented as per care plan. Additionally, although offloading of Resident #8's heels was not observed on 01/05/2026 and 01/09/2026 the certified nurse aide tasks documented offloading had been provided.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and Abbreviated Survey (#2638932), the facility did not ensure each resident received necessary respiratory care in accordance with professional standards of practice for two (2) of three (3) residents (Resident #12 and Resident #149) reviewed for Respiratory Care. Specifically, 1. Resident # 12 did not receive the correct oxygen flow rate of 6 liters per minute as per physician order and 2. Resident #149 did not receive the correct oxygen flow rate of 3 liters per minute as per physician order.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey from the facility did not ensure that drugs and biologicals were maintained in accordance with current professional standards for storage, labeling and expiration dates. Specifically, 1. observation of the fifth-floor medication cart revealed an insulin pen with no open date or discard date, and 2. one 15-gram tube of triamcinolone cream 0.1%, and one tube of diclofenac gel 1% were on the bedside table in Resident 108's room.

Inspectors wroteBased on observations and interviews during an abbreviated survey (NY00338612/591526, NY00355525/591523) the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, on every unit in the facility there were multiple areas of chipped paint, scuff marks, visible dirt and stains on the walls and floors, base boards coming off the wall, wallpaper bubbling up and foul odors noted.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00367889/591527, NY00333553/591524, NY00349962/591497) the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 3 of 5 residents (Resident #1, #2, #5) reviewed for care planning. Specifically, 1) Resident #1 had an unwitnessed fall on 01/1/2025 and sustained skin tears to both arms. Resident #1 had no documented fall risk or actual fall care plan initiated before or after the incident. 2) Resident #2 was noted to have eschar to their left heel on 02/11/2024. Resident #2's pressure injury care plan had not updated with the presence of the left heel eschar, measurements and/or tracking. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00367889-591527, NY00367906-591522), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for safety and supervision. Specifically, on 01/01/2025 Resident #1 told Certified Nurse Aide #1 that they needed to get out of bed otherwise they were going to jump out. Certified Nurse Aide #1 left the resident alone in their room after the resident made the statement. When Certified Nurse Aide #1 returned to Resident #1's room, the resident was on the floor. Resident #1 sustained skin tears to both upper extremities.

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (NY00362050), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately but no later than 2 hours to the New York State Department of Health (NYS DOH). This was evident for 1 of 3 residents (Residents #1) reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/21/2024 left the facility undetected by facility staff on 11/26/2024. The Facility staff did not realize Resident #1 was not in the facility until dinner time (approximately 5:30pm-6pm) and did not report the incident to State Agency Department until 11/27/2024.

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (NY00362050), the facility did not ensure that residents were provided adequate supervision/monitoring to prevent elopement. This was evident for 1 of 3 (Resident #1) residents reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/12/2024 exited the facility through the front door on 11/26/2024 at approximately 11:30 am undetected by facility staff. The resident was found on 12/2/2024 by Los Angeles Police Department who called the facility to report that the resident was brought to Los Angeles Police Department General Psych for evaluation.

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00362050), the facility did not ensure Certified Nurse Aide performance appraisals were completed at least once every 12 months for 2 of 3 Certified Nurse Aides record reviewed. Specifically, performance appraisals were not documented every 12 months for Certified Nurse Aide #2 and #3.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00352478), the facility did not ensure the Minimum Data Set assessment accurately reflected the resident's status for 1 out of 3 residents reviewed for assessments. Specifically, Resident #1's Quarterly Minimum Data Set assessment dated [DATE] coded the resident as dependent for all cares with 2-person assistance. The Quarterly Minimum Data Set, dated [DATE] coded the resident as dependent but requiring a 1 person assist which is not indicative of dependence for care. In addition, staff interview revealed a discrepancy on Resident #1's required assistance with bed mobility and the Certified Nurse Assistant Task Instructions/Accountability did not accurately reflect required assistance for Resident#1.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00352478, NY00350699), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 out of 3 residents reviewed for activities of daily living. Specifically, there was no documented evidence that a comprehensive care plan was initiated after the Quarterly Minimum Data Set assessment dated [DATE], that documented that the resident was dependent for all cares. In addition, the care plan did not accurately reflect the required assistance for a resident dependent for all cares on the Certified Nurse Assistant Task Instructions/Accountability. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey ( NY00350699), the facility did not ensure that a comprehensive person-centered care plan was reviewed and revised for 1 out of 3 residents (Resident #2) reviewed for care planning. Specifically, Resident #2 had a self-reported fall on 7/24/2024 and their actual fall care plan was not updated to reflect it.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00352478, NY00350699), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance to prevent accidents for 1 out of 3 residents reviewed for accidents. Specifically, on 8/21/2024, Resident #1 who had been identified as totally dependent with cares (helper completes all activities for the resident, resident does not use any of their own strength for any part of the activity), fell off the bed when Certified Nursing Assistant #1 was providing care by themself. Resident #1 sustained an unstable cervical spine C4-C5 fracture and possible left femoral neck fracture with deep forehead lacerations 4.5cm long and 0.1cm depth across forehead, swollen upper lip and gums and right nares. [...]

Inspectors wroteBased on observation and interview conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure housekeeping and maintenance services were provided to maintain a clean, comfortable, and homelike environment on 3 of 6 units. Specifically, observations included loose toilet seat/commode, spackled walls in halls and rooms in need of paint, broken handrails fixed with tape, walls adorned with various sections displaying black streaks and chipped paint, a hole in a wall, and the pungent smell of urine in multiple rooms.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure that resident Minimum Data Set assessments (MDS-an assessment tool) accurately reflected the resident's status. This was evident for 4 of 5 residents (Residents # 138, #5, #77, and #1) reviewed for MDS accuracy. Specifically, 1) the significant change MDS for Resident # 138 did not address that a stage 3 pressure ulcer was present on admission; 2) the MDS for Resident # 5 did not address administration of insulin or antidepressants; 3) the MDS for Resident #77 documented other restraints not used daily, but the resident did not have any documented or observed restraints; and 4) the MDS for Resident #1 documented, 'other restraints not used every day', but the resident did not have any documented or observed restraints.

Inspectors wroteBased on observations, record review and interview conducted during the Recertification Survey from 11/27/2023 to 12/5/2023, the facility did not ensure a resident was assessed by the interdisciplinary team to determine the resident's ability to safely administer their own medications if clinically appropriate for 1 of 1 resident (Resident #78) reviewed for self-administration of medications. Specifically, Deep Sea/Fluticasone Propionate nasal sprays and Ventolin/Symbicort inhalers were stored at the resident's bedside intended for the resident to self administer their own medications.

Inspectors wroteBased on interview and record review during the Recertification Survey from 11/27/23 to 12/5/23 it was determined that for one of 2 residents (Resident #129) reviewed for choices, the facility did not ensure that each resident had the right to make choices about aspects of life that were significant to them. Specifically, Resident #129's choice of when to get out of bed in the morning was not consistently honored.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 11/27/23 to 12/5/23, the facility did not ensure that they provided the appropriate liability and appeal notices to Medicare beneficiaries for 2 of 3 residents (Residents #278 and #600) reviewed for Beneficiary Notification. Specifically, the facility was unable to provide documented evidence that Residents #278, and #600 or their representatives received the Notice of Medicare Non-Coverage (NOMNC) for Medicare Part A at least two calendar days before Medicare covered services ended as required.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 11/27/23 to 12/05/23, the facility did not ensure that the resident or the resident's representative was given a timely written notice of the facility's bed hold policy upon transfer to the hospital for 2 of 2 residents reviewed for hospitalization. Specifically, there was no documented evidence that Residents #144 and #125 and/or their representatives were given a timely written notice of the facility's bed hold policy upon transfer to the hospital.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure each resident had a person-centered comprehensive care plan implemented to addresses the resident's medical and physical needs for 1 (Resident #60) of 4 residents reviewed for care plan implementation. Specifically, for Resident #60 the facility did not implement proper footwear as planned.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure they reviewed and revised the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 1 of 1 resident (Resident #11) reviewed for communication. Specifically, Resident #11 communication care plan did not reflect their current communication status.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Abbreviated surveys (NY00314899 and NY311919) from 11/27/23 to 12/5/23, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Resident #578, reviewed for quality of care. Specifically, 1) Resident #578 refused medications and treatments, and the facility did not inform the health care provider or document in the resident's electronic medical record (EMR); 2) Resident #87's behavior (spitting) was not evaluated to determine if it was contributing to weight loss. 3) Resident #125 was not provided seizure medications as ordered for a total of 34 omissions in March 2023. [...]

Inspectors wroteBased on record reviews and interviews during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure that Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months. Specifically, performance evaluations were not conducted every 12 months for four of five (CNA #11, #10, #2, and #9) records reviewed.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure that all drugs and biologicals used were stored in accordance with professional standards for 2 of 2 residents reviewed for Medication Storage. Specifically, 1. Resident #78 was observed with medications unsecured and unsupervised, on their bedside table and 2. Resident #174 was observed unsupervised, with medications on their meal tray.

Inspectors wroteBased on observation, record review and interview during the Recertification Survey from 11/29/23 to 12/5/23, the facility did not ensure that staff maintained 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. Specifically, 1. A Certified Nurse Aide (CNA) #1 was observed not using Personal Protective Equipment (PPE) or washing their hands appropriately while assisting Resident (# 59) who was on contact precautions. 2. A CNA did not use a barrier when assisting Resident # 131 with eating a sandwich.

Inspectors wroteBased on observations record reviews and interviews during the Recertification Survey it was determined that the facility did not ensure that based on the comprehensive assessment a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. Specifically, the clinical staff did not provide post operative assessment, care planning and treatment for Resident #72, who returned to the facility after multiple surgeries. (5) Resident #72 is a [AGE] year-old male with admitting diagnoses of schizophrenia, end stage renal disease status post AV graft formation (a surgical procedure to form an access for hemodialysis) and left kidney removal, hypertension, and diabetes. The MDS 9/4/20 indicated the resident is cognitively intact and requires extensive/1-person assist with bed mobility, toileting and dressing. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey, the facility did not ensure that appropriate care and services were provided according to professional standards to promote the practicable wellbeing for 4 of 4 residents ((1) #93, (2) #162, (3) #59, (4) #159 reviewed for positioning and mobility. Specifically, residents #59, #93, #159 and #162 were observed with clenched fist without hand rolls or splints in place to prevent contractures.

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure the right to participate in the development and implementation of person-centered plans of care, including but not limited to the right to participate in the planning process and attend care planning meetings. This was evident for 2 of 2 residents (Residents #113 and #55) reviewed for care planning. Specifically, resident # 113 has not participated in the planning process and has not participated in a care planning meeting, and resident #55 also has not participated in a care plan meeting.

Inspectors wrote[NAME], [NAME] A. (41666) Based on interview and record review conducted during the most recent recertification survey, the facility did not report to the New York State Department of Health (NYS DOH) an unwitnessed fall incident that resulted in a major injury to resident (#158). This was evident for 1 out of 1 resident reviewed for accidents.

Inspectors wroteBased on observation, interview and record review during a recertification survey the facility did not ensure that the facility developed and implement a resident centered care plan with measurable objectives for residents in need of positioning devices. Specifically, (1) resident #93 and (2) resident #162 were observed during the initial screening process with bilateral hand contractures with no devices in place.

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification and Abbreviated survey (Complaint # NY00249941) the facility did not ensure that physician's orders and resident's advance directives were reviewed prior to initiating CPR (Cardio Pulimonary Resuscitation). Specifically, the ADN (Assistant Director of Nursing) initiated CPR on Resident #1 who had a MOLST (Medical Orders for Life Sustaining Treatment) form and Physician's Orders that identified the resident's choice for DNR (Do Not Resuscitated). This was evident for 1 out 3 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility failed to employ a qualified social worker on a full time basis. Specifically, this facility has a licensed bed capacity of 200. From 04/15/20-08/24/20 it operated without a qualified full time Social Worker (SW) in its employ.