Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Martin Coast Center For Rehabilitation And Healthc during CMS and state inspections, most recent first.
Residents repeatedly raised unresolved grievances about delayed call light response and staff speaking foreign languages in resident rooms. A cognitively intact resident reported waiting 1 to 4 hours for help every day, including 3.5 hours after a BM, while other residents described call bells ringing for 35 minutes, repeated unanswered calls, and delays during evening and overnight shifts. Residents also said the language issue continued despite prior warnings, and one resident stated that concerns brought to Resident Council were not resolved.
Delayed IDT Assessment and Unsecured Meds for Self-Administration A resident with cognitive impairment and another resident with a trach were allowed to handle meds without timely IDT assessment and complete documentation of self-administration. One resident reported inhalers and OTC meds had been kept at the bedside for weeks, while staff lacked evidence of an IDT self-administration assessment and the education form did not address storage. The other resident had orders for unsupervised Budesonide and self-care, but the self-administration evaluation was completed later, and surveyors observed Budesonide and hydrogen peroxide unsecured at the bedside while the resident said he administered the treatments himself.
Unsafe and poorly maintained bathroom conditions were observed in multiple resident rooms on the 300 unit. Surveyors found emergency cords positioned improperly, including cords tied in knots, threaded through toilet tissue dispensers, wrapped around grab bars, and hanging too high from the floor. Other findings included a missing toilet seat cover, a bathroom windowpane with no privacy covering, and damaged bathroom doors with cracks and holes. The DOR acknowledged the concerns and stated the emergency cords should be free hanging and no more than about six inches from the floor.
Failure to Provide Nail Care: A resident with COPD, arthritis, and muscle weakness had an ADL self-care deficit and a care plan intervention for staff to trim and clean his nails on bath day and as needed. Surveyors observed both hands with fingernails about one half inch past the fingertips and sediment under the nails, and the resident stated he did not have anybody to clean them and did not like them that long. An LPN later confirmed the nails were too long and needed to be cut.
A resident with low BP had BP meds held based on the RN’s independent judgment, but communication with the NP was incomplete and the record lacked documentation of a later dose being given. The same resident’s admission skin assessment also failed to document a right leg wound/dressing that was observed on the resident, despite other skin findings being recorded.
Failure to address hand contractures: A resident with gout, RA, polyneuropathy, arthritis, and dementia was observed with both hands contracted and fingers curled into the palms. The CNA confirmed the resident did not open her hands, and the record showed no hand appliance orders, no physician mention of the contractures, and no splinting or orthotic treatment from therapy.
Failure to document trach care and maintain bedside emergency equipment for a resident with trach status. The resident had orders for daily trach care, self-laryngectomy care, and suction PRN, but the MAR/TAR and nursing notes showed no trach care documentation over the review period. During observation, no suction machine was in the room, and the RN unit manager acknowledged the resident did not have one at bedside; the resident said he performed his own care, while the MD and NP stated daily care and bedside emergency supplies were expected.
Bed Rail Assessments and Use Not Properly Completed: The facility failed to properly assess and document bed rail use for three residents. Two residents with severe cognitive impairment were observed with side rails/enablers in place even though the side rail assessments stopped after staff marked them immobile, and one resident’s side rail evaluation and consent were not in the electronic record when reviewed. The DON acknowledged the findings and stated that if a resident is immobile the evaluation does not go further and the resident is not appropriate for side rails.
Controlled medications were not removed from med carts after discontinuation for two residents. Lorazepam orders had been stopped, but the medication still appeared in the controlled drug records and remained on the carts during review. An LPN stated discontinued controlled meds are removed from the cart, and the RN unit manager acknowledged the meds should have been removed immediately.
Failure to provide prescribed minced and moist diets: Three residents with orders for MM5 texture and thin fluids were observed receiving meals that did not match the required texture or moisture level. One resident with dementia and dysphagia was served crispy fried chicken with gravy only on top, another resident with a hx of esophageal food retention received a one-inch crusty piece of chicken, and a third resident with dementia and COPD received minced chicken with gravy only partially covering the food. The RD and dietary leadership acknowledged the meal issues.
A resident with a BIMS score of 14 had a prior pneumococcal vaccine refusal documented in the EMR, but no further vaccine documentation was found. The IP said the vaccine was offered on admission and annually with flu consents, yet could not locate a current consent or declination. The resident stated she had not been offered the pneumonia vaccine and would want it if offered, while the ADON said the facility had no idea how she was missed.
The facility did not follow the approved menu for lunch, serving unbreaded chicken wings instead of 'Golden Fried Chicken' due to a supplier issue and lack of proper equipment. Residents were not informed of the menu change, and the portion size served did not meet the approved 4 ounces due to the presence of bones. The Dietary Manager acknowledged these issues during the survey.
The facility failed to adhere to food safety standards, as a dietary aide was observed without a beard restraint, and food items were stored at unsafe temperatures. Additionally, a carton of eggs brought in by a visitor was found unlabeled in a refrigerator, violating the facility's policy on handling outside food.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving four residents. A resident felt disrespected when CNAs spoke in another language, while another was denied a meal after dialysis. A cognitively impaired resident experienced neglect during meal times, and a resident with Alzheimer's was repeatedly prevented from standing, contrary to his care plan. These incidents highlight a lack of dignified care and communication by the staff.
A facility failed to provide showers according to a resident's preferences and schedule, despite the resident being cognitively intact and requiring assistance for mobility. The resident and her daughter reported infrequent showers since admission, contradicting the care plan that specified showers three times a week. Staff interviews revealed inconsistencies in communication and documentation, contributing to the deficiency.
The facility was found to have multiple deficiencies in maintaining a safe, clean, and homelike environment across several units. Observations included damaged walls, worn wheelchair seats, damaged over bed tables, a strong urine odor, stained ceiling tiles, and mold-like residue in the shower room. The Maintenance Director and Housekeeping/Laundry Supervisor acknowledged these issues, but no specific timeframe for repairs was provided.
A resident with mild cognitive impairment was not involved in his care planning process, despite having no documented power of attorney or health care surrogate. The resident's sister attended meetings and made decisions without his consent. Facility records lacked evidence of the resident being invited to participate, leading to a deficiency finding.
The facility failed to provide grooming assistance to three residents who required staff support for ADLs. Observations revealed unwashed, greasy hair and long fingernails, with staff interviews confirming neglect in care. Residents in the memory care unit, with severe cognitive impairments, did not receive regular showers or nail care, despite documented needs and expressed importance of such care.
Facility staff failed to assess lung sounds and vital signs before and after nebulizer treatments for three residents, contrary to the facility's respiratory care policy. An LPN relied on the absence of a cough to determine clear breathing for a resident, while another LPN was unaware of the need for additional assessments. A third LPN admitted to forgetting to check pulse oxygenation and did not auscultate lung sounds, indicating a consistent failure to adhere to required procedures.
A facility failed to manage a resident's pain appropriately by not following the physician's order for a lidocaine patch application and removal. An LPN applied the patch, but it was not removed or replaced the next day as required. The MAR inaccurately documented the patch's removal and replacement, which was contradicted by the observation of the dated patch. The DON was informed and agreed with the concern.
A resident in a facility expressed a desire to leave and reported being unable to make healthcare decisions, despite having no legal documentation appointing a power of attorney. The resident's sister was involved in care plan meetings without his consent, and his grievances about discharge wishes and financial concerns were not addressed. The social services director did not provide assistance in resolving these issues, leading to a deficiency in meeting the resident's needs and advocating for his rights.
The facility failed to use appropriate PPE for a resident with a tracheostomy and PEG tube, as an LPN did not don a gown or change gloves between procedures. Additionally, the facility delayed implementing contact isolation for a resident suspected of having C. difficile, starting precautions five days after symptoms began, contrary to the ICP's acknowledgment that precautions should start with symptom onset.
A resident experienced discomfort due to an inadequate mattress that allowed her to feel the bed frame, despite the mattress being rated to support her weight. The facility lacked proper communication and documentation regarding mattress audits and checks, leading to the oversight. Staff interviews revealed gaps in the process of ensuring appropriate mattresses for residents, particularly during room changes.
A facility failed to develop a protocol for releasing medical records requested by a resident's legal representative, leading to a deficiency. The medical record request log lacked entries for the resident, and requests were improperly forwarded to former owners without tracking. The NHA revealed that requests are sent to a third-party vendor for validation, but the process was mishandled due to a lack of written policy and new staff.
Delayed Call Light Response and Unresolved Resident Council Grievances
Penalty
Summary
The facility failed to act promptly on grievances raised during Resident Council meetings regarding long delays in call light response and staff speaking foreign languages in resident rooms. Monthly council notes documented repeated complaints about call light wait times on 11/25/25, 12/30/25, 01/27/26, 02/24/26, and 03/31/26, including a note that nursing staff had long delays answering call lights most often during night shifts. The same council notes also documented ongoing concerns about staff speaking foreign languages in resident rooms. Resident #28, who was cognitively intact with a BIMS of 15 and required staff assistance with hygiene, repositioning, toileting, and dressing, reported waiting one to four hours after pressing the call light. He described one incident in which he waited three and a half hours to have his brief cleaned after a bowel movement and said his buttocks were stinging from sitting in the dirty brief. He stated that these long wait times occurred every day. Resident #48, also cognitively intact with a BIMS of 14 and needing staff assistance with toileting and other ADLs, reported that when she pressed the call light no one came and that she sometimes had to wheel herself to the bathroom because she could not walk. She said she was afraid of falling and that delayed responses also prolonged her pain when she needed PRN pain medication. During the Resident Council meeting, Resident #10 reported a call bell ringing continuously for 35 minutes, and Resident #52 described having to press the call light again after 15 to 20 minutes with no response, especially during the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. Resident #116 stated that problems brought up in Resident Council meetings were not resolved, including call light delays and staff speaking in another language. Resident #54 also reported concern that CNAs continued speaking in another language in front of residents despite being warned many times.
Delayed IDT Assessment and Unsecured Self-Administration of Medications
Penalty
Summary
The facility failed to ensure timely interdisciplinary team (IDT) assessment and documentation for residents who were self-administering medications. The facility policy stated that when a resident requests to self-administer medications, the IDT must determine that it is safe, decide who is responsible for storage and documentation, identify the location of administration, and obtain a physician order listing the medications that may be self-administered. The policy also required the determinations to be documented in the care plan. For one resident, the record showed a BIMS score of 11 with diagnoses including heart failure and respiratory failure. The admission evaluation documented that the resident did not have the desire to self-administer medications, and the progress notes and care plan lacked documentation related to self-administration. During interview, the resident stated that inhalers, Tums, and Gas X had been kept at the bedside for about 6 weeks and that staff had told him to place the medications in the top drawer. An order later documented unsupervised self-administration of a rescue inhaler, but the Unit Manager stated she was not aware of any self-administration assessment form with IDT input and that the resident’s education form did not address storage or IDT involvement. For another resident, the record showed diagnoses including malignant neoplasm of the larynx and epiglottis, paralysis of the vocal cords and larynx, and tracheostomy status, with a BIMS score of 15. The physician’s orders included Budesonide inhalation suspension for unsupervised self-administration and an order for the resident to perform self-laryngectomy care and nebulizer self-administration, but there was no self-administration evaluation completed until later. The care plan stated the resident could self-administer nebulizer treatments as ordered, yet an observation found two vials of Budesonide on the windowsill and an open bottle of hydrogen peroxide on top of the air conditioning unit. The resident stated he administered the treatments himself and had been storing the medications unsecured after losing the key to his nightstand, while nursing staff acknowledged the medications were supposed to be secured and that the resident would need to be assessed.
Unsafe and Poorly Maintained Bathroom Conditions in Multiple Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for 7 of 13 rooms on the 300 unit, including Rooms 306, 307, 311, 312, 313, 314, and 315. During observations on 04/06/26, surveyors found multiple bathroom emergency cords improperly positioned, including cords approximately 3 feet from the floor, threaded through toilet tissue dispensers, tied in knots, and wrapped around grab bars. In one room, the toilet was missing a toilet seat cover, and in another, the bathroom bottom windowpane was clear glass with no window covering for privacy. Additional observations found damage to bathroom doors, including a crack in the bottom of one door, a crack on the left side of another, and holes inside another bathroom door. During interview, the Director of Maintenance stated emergency cords should be free hanging and function when pulled. During a side-by-side tour, the Director of Maintenance acknowledged the concerns and stated the 300 unit had just been started for renovation, and that the emergency cords in the bathrooms should be freely hung and no more than approximately six inches from the floor.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide nail care for Resident #21, who had diagnoses including Chronic Obstructive Pulmonary Disease, muscle weakness, other lack of coordination, and arthritis. A significant change assessment documented a BIMS score of 14, indicating he was cognitively intact. His care plan identified an ADL self-care performance deficit related to COPD, arthritis, and muscle weakness, and included an intervention, in place since 07/19/24, for staff to trim and clean his nails on bath day and as necessary. During observations on 04/06/2026 and 04/07/2026, Resident #21's fingernails were noted to be long, approximately one half inch past his fingertips, with light brown to medium brown sediment under the nails on both hands. When interviewed, Resident #21 stated, "I don't have anybody to clean them. I don't like them so long." Staff M later observed the nails and stated they were too long and needed to be cut, adding that Resident #21 liked his nails short.
Medication Communication and Admission Skin Assessment Deficiencies
Penalty
Summary
The facility failed to effectively communicate and document medication decisions for a resident with low blood pressure readings on two consecutive days. During a medication administration observation, the RN re-checked the resident’s blood pressure and, based on her own judgment, held spironolactone and amlodipine when the reading was 109/54, telling the resident the blood pressure was in a good range. The RN stated she generally held blood pressure medications when the upper reading was below 110 and would re-check the blood pressure two hours later, then give the medication if the reading increased above 110. Record review showed that on the prior day the same RN had held only amlodipine for a blood pressure reading of 98/63, and the record lacked documentation that the amlodipine was later administered. During interview, the nurse practitioner stated she had been told the resident’s blood pressure was under 110 and that blood pressure medications were held, but she was not told which medication had been held and was unaware the RN later gave the amlodipine back on the prior day. The RN acknowledged she should document all interventions and stated she may have forgotten to document the follow-up administration when in a hurry. The facility also failed to ensure an accurate admission skin assessment for the same resident. The record contained multiple skin assessments that documented bruising, discoloration, a right foot wound, and bruising to the jaw, but none documented the dressing or open area on the resident’s right leg. During observation, a bordered dressing dated 3/30 was noted just below the resident’s right knee, and the resident was unsure what had happened. The unit manager reviewed the assessments and agreed that the wound care nurse’s skin assessment lacked documentation related to the right leg.
Failure to Address Hand Contractures
Penalty
Summary
The facility failed to identify and treat hand contractures for Resident #94, who was admitted with diagnoses including gout, glycoprotein disorders, rheumatoid arthritis, polyneuropathy, arthritis, and dementia without behavioral disturbance. A quarterly assessment noted memory problems and a need for assistance with feeding. Her care plan for chronic pain related to neuropathy and arthritis included interventions for physical activity to strengthen and improve mobility, as well as staff observation and reporting of decreased functional abilities and decreased range of motion. During an observation, both of Resident #94's hands were found in her lap under a folded blanket, and when the blanket was removed, both hands were contracted with fingers curled toward the palms. The CNA stated that the resident did not open her hands and kept her fingers curled in like closed hands. Record review showed no orders for a hand appliance to decrease the risk of further contracture, and physician notes contained no mention of hand contractures. The Director of Rehabilitation stated that the resident had no splinting or orthotic treatments for her hands and that therapy did not provide treatment for the hand contractures.
Failure to Document Tracheostomy Care and Keep Emergency Equipment at Bedside
Penalty
Summary
The facility failed to ensure tracheostomy care was performed and documented for a resident with diagnoses including malignant neoplasm of the larynx, malignant neoplasm of the anterior surface of the epiglottis, paralysis of the vocal cords and larynx, and tracheostomy status. The resident’s record showed orders for self-laryngectomy care, daily trach care, and suction as needed, but the MAR/TAR and nursing progress notes contained no documentation of trach care being performed by staff or the resident from 03/23/26 through 04/06/26. The care plan noted the resident had a laryngectomy tube, did his own laryngectomy care, and refused staff treatment of the trach. During observation on 04/06/26, the resident was sitting on the edge of the bed with a tracheostomy in place, and no suction machine was observed in the room. In interview, the resident stated he did all of his own tracheostomy care. The primary physician stated there should be standing orders for stoma site care and that no staff had contacted him about stoma care. The nurse practitioner stated tracheostomy care should be provided daily and documented, and that emergency supplies should include a suction machine, an Ambu bag, and a replacement tracheostomy tube at the bedside. The unit manager acknowledged the resident did not have a suction machine at the bedside.
Bed Rail Assessments and Use Not Properly Completed
Penalty
Summary
The facility failed to remove bed rails for residents who were assessed not to have them and failed to obtain appropriate assessments for a resident who was able to have bed rails for 3 of 3 residents reviewed. Resident #11 was admitted with diagnoses including dementia with psychotic disturbances, anxiety disorder, Parkinson’s disease, and wandering, and her MDS documented a BIMS of 00 indicating severe cognitive impairment. During multiple observations, she was seen with side rails/enablers up on her bed. Her record included physician orders for side rails, a care plan for bilateral adaptive side rails for bed mobility, and a consent that was present but not filled out or signed. The side rail assessments in the record were dated quarterly, but each showed only the initial question answered that the resident was immobile, with no further determination completed. Resident #69 was admitted with dementia and depression, and her quarterly MDS documented a BIMS of 00 indicating severe cognitive impairment. Her record included a physician order for bilateral adaptive side rails for bed mobility, a care plan identifying adaptive side rails, and a side rail assessment dated 10/03/25 that also stopped after the question asking whether the resident was immobile was answered yes. During multiple observations, she was seen with side rails/enablers up on her bed. Resident #78 was admitted with diagnoses including left hip fracture, diabetes mellitus, and major depressive disorder, and her MDS documented a BIMS of 5 indicating severe cognitive impairment. A side rail evaluation and consent were not located in the electronic record, although staff later showed the surveyor an evaluation and consent dated 03/10/26. A physician order for adaptive side rails was entered on 04/08/26 while surveyors were onsite, and the care plan for side rails was also dated 04/08/26. During multiple observations, she was seen with side rails/enablers up on her bed. The DON reviewed the records and acknowledged the findings, including that if the resident is immobile the evaluation does not go further and the resident is not appropriate for side rails.
Controlled medications remained on med carts after discontinuation
Penalty
Summary
The facility failed to follow its policy for discarding and destroying medications and for maintaining controlled drug records in order for two residents. Review of the policy stated that controlled substances must be disposed of immediately, no longer than three days, after discontinuation of use by the resident. For Resident #20, a physician order for lorazepam 0.5 mg half tablet by mouth once daily as needed was discontinued on 06/26/25, but during a medication cart review on 04/09/26 the lorazepam was still listed in the controlled medication monitoring records and remained on the 300-unit med cart. Staff K, LPN, stated that controlled medications are removed from the cart when discontinued. For Resident #50, an order for lorazepam 0.5 mg, 2 tablets by mouth every 6 hours as needed, was discontinued on 02/06/26, but during a review of the 400-unit med cart on 04/09/26 the lorazepam was still included in the controlled medication records and remained on the cart. Staff L, LPN, stated that when controlled medications are discontinued, she brings them to the DON. Staff H, RN Unit Manager, stated that discontinued controlled medications should be removed immediately and acknowledged that both residents’ lorazepam should have been removed from the medication carts when the orders were discontinued.
Failure to Provide Prescribed Minced and Moist Diet
Penalty
Summary
The facility failed to provide the prescribed minced and moist diet to 3 of 3 sampled residents, with the issue affecting 9 residents who were on that diet. The facility’s IDDSI policy stated that Level 5 minced and moist foods must be finely minced or chopped into small pieces, approximately 4 mm in size, and moistened with gravy, and that dry, hard, crispy, and crusty foods should be avoided. Record review showed that Resident #77 had diagnoses including dementia and oropharyngeal dysphagia and had an order for a regular diet with minced and moist texture and thin fluids. During lunch observation, she was served clusters of crispy fried chicken with thick gravy placed on top rather than mixed into the food, and the chicken was not minced to the required texture. Resident #132 had diagnoses including muscle wasting and atrophy and GERD, with a history of retained food removed from the esophagus, and had an order for a regular diet with minced and moist texture and thin fluids. During lunch observation, she was served mostly minced chicken, but one piece was about one inch long with dark crusty edges and was not minced. Resident #3 had diagnoses including muscle weakness, COPD, and dementia, and had an order for a regular diet with minced and moist texture and thin fluids. During lunch observation, she was served minced chicken with thick gravy on only about 35-40% of the food, leaving areas without gravy. The Registered Dietitian observed the meal and stated that the chicken on the edges of the plate had no gravy and that it would be adequate if mixed in. The Dietary Manager and Registered Dietitian later reviewed the meal photo, and the kitchen manager agreed with the finding.
Missed Pneumococcal Vaccine Offer and Documentation
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered and provided for one sampled resident. Resident #48 was admitted on 04/20/23, and the Quarterly MDS documented a BIMS score of 14, indicating the resident was cognitively intact. The electronic medical record immunization tab showed that the resident refused the pneumococcal vaccine on 06/28/23, but there was no further documentation related to that vaccine in the record. During record review and interview, the Infection Preventionist stated that the pneumococcal vaccine was offered upon admission and annually when flu vaccine consents were obtained, but she could not find evidence of a current consent or declination for Resident #48. In interview, the resident stated she had not been offered the pneumonia vaccine and said she would want it if offered. Staff D stated the resident could be a little confused at times but was alert and oriented and able to make her needs known. The ADON stated the facility had no idea how the resident was missed for the pneumococcal vaccine this past season.
Failure to Follow Approved Menu and Notify Residents of Changes
Penalty
Summary
The facility failed to adhere to the approved menu for lunch on 11/06/24, which specified serving 'Golden Fried Chicken'. Instead, residents were served chicken wings that lacked the appearance and preparation of the specified dish. The kitchen lacked the necessary equipment, such as a fryolator or deep fryer, to prepare the chicken as per the approved recipe. The Dietary Manager explained that the supplier was out of the fried chicken that was supposed to be served, and the chicken was pan-fried instead. Additionally, the facility did not notify residents of the menu change, as the posted menu still indicated 'Golden Fried Chicken'. Furthermore, the facility did not serve the correct portion size as per the approved menu, which specified 4 ounces of fried chicken. During the meal service, it was observed that residents were served 3 bone-in chicken wings, which, when weighed, included a significant portion of inedible bone. The Dietary Manager acknowledged the oversight in portion size due to the presence of bones and instructed staff to add an additional chicken wing to the meals already plated. This failure to follow the approved menu and portion sizes resulted in a deficiency noted by the surveyors.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food safety standards during meal preparation, storage, and service. During an initial kitchen tour, a dietary aide was observed handling open foods and working with food equipment without wearing a beard restraint, which is a violation of sanitary practices. The Dietary Manager had to instruct the staff member to put on an appropriate hair restraint. Additionally, during a follow-up kitchen tour, it was found that cut melons and deli sandwiches were stored at unsafe temperatures, 51 degrees Fahrenheit and 49 degrees Fahrenheit respectively, due to being placed on a speed rack next to a hot holding area without adequate cooling measures. The Dietary Manager acknowledged the temperature issue and directed staff to move the items to a cooler. Furthermore, the facility's policy on food brought in by family or visitors was not adhered to, as evidenced by a carton of eggs found in a unit pantry refrigerator without proper labeling. The eggs were in a plastic grocery bag with no indication of which resident they were for or when they were placed in the refrigerator. This oversight in labeling and dating violates the facility's policy designed to ensure the safety of residents consuming food brought in from outside sources.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by multiple incidents involving four residents. Resident #36, who is cognitively intact, reported feeling disrespected when CNAs spoke in another language in front of her, making her feel as though they were talking about her. She also expressed that staff ignored her requests at the nurses' desk, leading to feelings of isolation and disrespect. Despite her desire to address these issues, she refrained from doing so out of fear of staff retaliation. Resident #86, also cognitively intact, recounted an incident where a CNA refused to provide her with a meal after returning from dialysis, instead offering a peanut butter and jelly sandwich, which she declined. The CNA's dismissive response, suggesting she retrieve the food herself despite her inability to walk, left her feeling disrespected. Like Resident #36, she did not report the incident due to fear of further mistreatment by the staff. Resident #8, who is cognitively impaired and visually impaired due to glaucoma, experienced neglect during meal times. Despite repeatedly asking if she would receive food, staff delayed serving her meal and failed to address her concerns. Resident #83, who has Alzheimer's dementia and is at high risk for falls, was repeatedly prevented from standing by staff, despite being able to walk with assistance. The staff's approach was not in line with the care plan, which emphasized gentle and supportive interaction to encourage mobility.
Failure to Provide Showers Per Resident's Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers according to the resident's preferences and the established shower schedule. Resident #309, who was cognitively intact and required substantial assistance for bed transferring and moderate assistance for bed mobility, expressed that she had not been showered since her admission. Her daughter corroborated this, stating that the resident had only been showered twice since admission. The resident's care plan specified showers on Tuesday, Thursday, and Saturday evenings, but records showed that the resident received showers only five times in the past 30 days, with no documentation of refusal. Interviews with staff revealed a lack of consistent communication and documentation regarding the resident's shower schedule. Staff C, a CNA, mentioned that the resident never refused showers and that any refusals would be reported to a supervisor. Staff D, an RN Supervisor, indicated that they signed off on shower sheets, which were then sent to the Unit Manager. Staff E, an LPN/UM, stated that the shower sheets matched the electronic health record and claimed to have daily conversations with the resident and her family, who reportedly did not mention any issues with showers. Despite these assertions, the facility did not adhere to the resident's shower schedule, leading to the deficiency.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across multiple units, as observed during a survey. On the 200 unit, several rooms had damaged walls, while on the 300 unit, issues included worn wheelchair seats, damaged over bed tables, and a persistent strong urine odor. The 400 unit had stained ceiling tiles, damaged wheelchair arms, missing television remotes, stained privacy curtains, and damaged walls and over bed tables. Additionally, the air conditioning unit indicated a need for filter maintenance. In the shower room on the 100 unit, there was damage to the baseboard and wall, a damaged kick plate on the door, and a black mold-like residue on the walls and grout. The Maintenance Director and Housekeeping/Laundry Supervisor acknowledged these issues, and the Administrator noted that the facility was undergoing changes following a recent Change of Ownership (CHOW). However, no specific timeframe for repairs and replacements was provided.
Resident Excluded from Care Planning Process
Penalty
Summary
The facility failed to ensure the participation of a resident in the development of his care plan and ongoing participation in care planning meetings. The resident, who was assessed to have a mildly impaired mental status, expressed his dissatisfaction with not being involved in his health care decisions and stated that he was not invited to any care plan meetings. Despite having no documented power of attorney or health care surrogate, the resident's sister was invited and attended the care plan meetings, making decisions on his behalf without his consent. The facility's records showed no documentation of the resident being invited to the meetings, and staff interviews confirmed the lack of evidence for such invitations. The resident claimed to be illiterate, which was contradicted by the social worker who observed him reading. The facility's failure to involve the resident in his care planning process and the absence of documentation supporting the sister's involvement without the resident's consent were identified as deficiencies.
Failure to Provide Grooming Assistance to Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance, including hair washing and nail care, to three residents who were dependent on staff for their activities of daily living (ADLs). Resident #28, residing in a secured memory care unit, required substantial assistance for ADLs due to communication problems and impaired understanding. Despite this, the resident had only received one shower in the past month, and observations over several days revealed unwashed, greasy hair. Staff interviews indicated a lack of consistent care, with a CNA unable to confirm regular hair washing. Resident #40, also in the memory care unit, was severely cognitively impaired and needed substantial assistance for showering. Observations showed the resident's hair was consistently greasy over several days. Resident #44, with severe cognitive impairment, expressed the importance of bathing but had no documented refusals of care. Observations revealed greasy hair and excessively long fingernails, with the resident's Power of Attorney expressing concerns about the lack of grooming. Staff interviews confirmed the neglect in providing necessary ADLs, with a CNA admitting to not trimming the resident's nails and an LPN acknowledging the oversight.
Failure to Assess Respiratory Status During Nebulizer Treatments
Penalty
Summary
Facility staff failed to properly assess lung sounds and vital signs before and after administering nebulizer treatments to three residents. The facility's policy on respiratory care and oxygen administration requires evaluation of respiratory status, breath sounds, and response to treatment to be documented in the clinical record. However, observations revealed that staff did not adhere to these guidelines. For Resident #42, the LPN only checked oxygen saturation and pulse rate, relying on the absence of a cough to determine clear breathing, without using a stethoscope to assess lung sounds as required. Similarly, Resident #95 received nebulizer treatments without the necessary pre and post-treatment assessments. The LPN administering the treatment was unaware of the need to complete additional vitals or assess lung sounds. For Resident #63, the LPN administered a nebulizer treatment without performing any pre or post-administration assessments, admitting to forgetting to check pulse oxygenation and failing to auscultate lung sounds. These actions indicate a consistent failure to follow the facility's respiratory care policy, potentially compromising resident care.
Failure to Administer Pain Management as Ordered
Penalty
Summary
The facility failed to ensure proper pain management for a resident by not adhering to the physician's order for the application and removal of a lidocaine patch. The resident had an order for a lidocaine 5% patch to be applied to the lower back daily at 9 AM and removed at 9 PM. During a medication pass observation, it was noted that the patch on the resident's back was dated two days prior, indicating it had not been changed as required. The LPN confirmed that she applied the patch on the specified date and did not work the following day, suggesting the patch was not removed or replaced as per the order. The MAR inaccurately documented that the patch was removed and replaced on the subsequent day, which was not the case, as evidenced by the observation of the dated patch. The Director of Nursing was informed of this discrepancy and acknowledged the concern.
Failure to Provide Adequate Social Services and Resident Advocacy
Penalty
Summary
The facility failed to provide sufficient and appropriate social services to a resident, leading to a deficiency in meeting the resident's needs. The resident expressed a desire to leave the facility and reported feeling unable to make his own healthcare decisions, despite having no legal documentation appointing a power of attorney or healthcare surrogate. The resident's sister was involved in care plan meetings without the resident's consent, and there was no evidence that the resident was invited to or attended these meetings. The resident also voiced grievances about his discharge wishes and financial concerns, which were not addressed by the facility's social services. The resident, who was assessed with a Brief Interview Mental Status score indicating mild impairment, reported that his sister had taken his house, car, and money, and he requested assistance in finding a lawyer. Despite these requests, there was no documentation showing that the social services director offered any assistance in resolving these issues. The resident's mental health evaluations indicated that he was alert, oriented, and capable of making his own decisions, yet the facility continued to involve his sister in decision-making without his consent. The social services director acknowledged the lack of documentation supporting the resident's inability to make his own decisions and confirmed that no assistance was provided to the resident in addressing his grievances. The facility's failure to involve the resident in his care planning and to provide necessary social services to address his concerns resulted in a deficiency in meeting the resident's needs and advocating for his rights within the facility.
Inadequate PPE Use and Delayed Contact Isolation
Penalty
Summary
The facility failed to ensure the appropriate use of Personal Protective Equipment (PPE) during the care of a resident with a tracheostomy and a percutaneous endoscopic gastrostomy (PEG) tube. The resident required Enhanced Barrier Precautions (EBP), which included the use of gowns and gloves for high-contact care activities. During a medication pass observation, a Licensed Practical Nurse (LPN) administered medication through the resident's PEG tube and tracheostomy without donning a gown and failed to change gloves between procedures. The Infection Control Preventionist (ICP) confirmed that PPE should be used during direct care, including medication administration via tracheostomy and PEG, but the LPN did not adhere to these precautions. Additionally, the facility did not implement timely contact isolation for a resident suspected of having Clostridioides difficile (C. difficile). The resident exhibited symptoms warranting a stool sample to rule out C. difficile, and the test was ordered. However, contact precautions were not initiated until five days after the symptoms began, despite the ICP acknowledging that precautions should have started when symptoms were first observed. This delay in implementing contact precautions was confirmed during an interview with the ICP.
Inadequate Mattress Support for Resident
Penalty
Summary
The facility failed to provide an appropriate mattress for a resident, leading to discomfort and potential risk for pressure development. The resident, who was cognitively intact and required assistance for transferring and bed mobility, reported feeling the bars of the bed frame through the mattress and noted that the bed controls were non-functional. Upon investigation, it was confirmed that the mattress did not adequately support the resident's weight, allowing her body to rest on the metal bed frame. Despite the mattress being rated to support up to 300 pounds, the resident, weighing 189 pounds, experienced discomfort and inadequate support. Interviews with facility staff revealed a lack of communication and documentation regarding mattress audits and checks. The Maintenance Director could not provide details or documentation of any mattress audits, and the Wound Care Nurse was unaware of the resident's complaints. The Unit Clerk indicated that the Unit Manager was responsible for ensuring appropriate mattresses based on hospital information, but there was no evidence of this process being followed. Additionally, the Housekeeping/Laundry Supervisor confirmed that mattresses were not checked during room changes, and the most recent quarterly audit did not document any concerns related to the resident's bed.
Failure to Develop Protocol for Medical Record Requests
Penalty
Summary
The facility failed to develop a protocol for the release of medical records requested on behalf of a resident's legal representative, resulting in a deficiency. The medical record request log from January 2024 to September 2024 showed no entries related to the resident in question. An interview with the Medical Records staff revealed that two requests for the resident's records were received, but these were forwarded to the former owners without a tracking mechanism to verify completion. The Director of Nursing acknowledged the lack of a process to handle such requests when they cannot be honored by the current facility. Further interviews with the Nursing Home Administrator (NHA) revealed that legal requests for medical records are sent to a third-party vendor for validation. The first request was denied, and the outcome of the second request was unclear due to it being sent to the wrong person. The NHA noted that the staff responsible for handling these requests was new to the position and that there was no written policy or protocol to ensure that legal requests submitted on behalf of a resident's representative are honored.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hobe Sound
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seabranch Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 3 | 0 |
| Solaris Healthcare Parkway | 8.4 mi | ★★★★★ | 8 | 0 |
| Stuart Rehabilitation And Healthcare | 8.5 mi | ★★★★★ | 6 | 0 |
| Palm City Nursing & Rehab Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Waters Edge Health And Rehabilitation | 10.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.