Inspection Reports for Marine Creek Nursing and Rehabilitation

The facility failed to ensure that 2 of 4 assisted lifting devices were properly secured while stored in hallways, creating potential accident hazards. Staff training on securing these devices had been conducted, but observations showed devices with unlocked wheels, posing risks to residents.

The facility failed to protect residents' right to a safe, clean, comfortable, and homelike environment for 20 of 31 residents in the secured unit due to a persistent strong urine smell on the male side of the unit observed over multiple days. Staff reported residents urinating in common areas, and the facility had not yet resolved ventilation issues despite ongoing efforts.

The facility was found deficient in reasonably accommodating resident needs and preferences, maintaining a safe, clean, and homelike environment, and ensuring adequate supervision to prevent accidents. Specific issues included call lights not within reach for some residents, a persistent strong urine smell in the secured unit affecting resident dignity, and a resident having unauthorized possession of isopropyl alcohol in their room.

The complaint investigation substantiated that Resident #23 physically abused Resident #45 by punching him in the face and hitting him in the stomach during a resident-to-resident altercation on 08/29/2025. Both residents were involved in verbal and physical aggression, with injuries documented on Resident #45. Police were called and both residents received citations for disorderly conduct.

The facility failed to protect Resident #45 from physical abuse by Resident #23, resulting in actual harm including injuries to Resident #45's face and chest. The investigation included interviews, record reviews, and observations confirming the altercation and subsequent injuries.

The facility was found deficient in maintaining residents' privacy and confidentiality, proper feeding tube medication administration, and infection prevention practices including gown and glove use. Multiple residents were affected by privacy breaches, improper g-tube medication administration, and lapses in infection control protocols, posing risks of harm and infection.

The complaint investigation revealed failures in emergency preparedness and respiratory care, including missing emergency equipment and inadequate oxygen therapy management for Resident #1, who was on hospice and passed away after receiving improper oxygen therapy.

The facility failed to ensure emergency crash carts were properly stocked and checked daily, including missing an Ambu bag on Emergency Cart 1 and failure to check inventory on Emergency Cart 2. Additionally, the facility failed to obtain physician orders for non-rebreather oxygen therapy for Resident #1, resulting in improper oxygen delivery settings and inadequate staff training on non-rebreather use, which contributed to Resident #1's death.

The facility failed to ensure that the formula and water bags for Resident #1's feeding tube were properly labeled with the date and time started, which could place residents at risk of malnutrition and dehydration. Observations and interviews confirmed the lack of proper labeling, and the facility's policy did not specify timing and dating requirements for feeding bags.

The complaint involved Resident #1 repeatedly calling 911 and the facility's response to remove her phone to prevent further calls. The Administrator was contacted by local police regarding abuse of the 911 system. The phone was taken temporarily and returned within about 10 minutes. The resident's death was not caused by the phone removal.

The facility failed to ensure that Resident #1 retained the right to use her personal cell phone, which was taken away by the Administrator due to repeated 911 calls. The phone was the resident's only means of communication with family and staff via text messages. The phone was returned within about 10 minutes, and the resident's death was not related to the phone removal.

The complaint investigation was triggered by a family member's report and video evidence of CNA B verbally abusing Resident #1 and using force to get her to bed on 10/31/2024. CNA B was terminated, and LVN A received training for failure to report the incident. Family members expressed concerns about staff behavior and handling of the incident.

The facility failed to prevent verbal abuse of Resident #1 by CNA B, who yelled and used inappropriate language towards the resident while trying to force her to bed. The facility also failed to maintain Resident #2's bedframe and mattress to prevent accidents and failed to maintain an effective pest control program, resulting in sightings of roaches and flies. Staff training and incident reporting deficiencies were noted.

The complaint investigation substantiated failures related to privacy violations for Resident #1 and inadequate respiratory care for Residents #5 and #16, including improper handling and cleaning of oxygen equipment and failure to maintain resident dignity.

The facility failed to ensure privacy for Resident #1 when a nurse did not use the privacy curtain while the resident was exposed. Additionally, the facility failed to provide proper respiratory care for Residents #5 and #16, including failure to bag nasal cannulas when not in use and failure to clean oxygen concentrators and filters, placing residents at risk for respiratory infections and distress.

The facility was found deficient in multiple areas including failure to accommodate residents' needs for call light accessibility, failure to maintain privacy and obtain consents for electronic monitoring, inadequate assistance with activities of daily living such as showering, improper care and maintenance of feeding tubes, lack of physician orders for ventilator settings, failure to maintain infection control practices including sanitization of blood sugar monitoring devices and use of PPE, and ineffective pest control program resulting in flies in the dining room.

The facility failed to ensure that two medication carts and one respiratory treatment cart were locked when unattended, potentially allowing residents or visitors unauthorized access to medications, posing a risk of medication loss or harm.

The complaint investigation focused on Resident #1, who was transferred to a hospital without the facility sending required discharge notifications to the Ombudsman or providing written discharge or bed-hold policy information to the resident or family. Interviews with the resident, family, social worker, marketing manager, administrator, DON, and business office manager confirmed failures in notification and discharge procedures.

The facility failed to send a written transfer or discharge notice to the Ombudsman and did not provide Resident #1 with written information about the bed-hold policy during her transfer to the hospital. Interviews and record reviews revealed inconsistent discharge practices and lack of proper notification to residents, families, and the Ombudsman.

The complaint investigation revealed that Resident #1's tracheostomy cuff was overinflated, leading to serious health complications including malnutrition and vertebral damage. The Immediate Jeopardy was identified on 06/27/24 and removed on 06/28/24 after the facility implemented corrective actions and monitoring.

The facility failed to ensure proper tracheostomy care for Resident #1 by overinflating the tracheostomy tube cuff beyond the recommended pressure, causing chronic injury to the resident's vertebrae and swallowing difficulties leading to malnutrition and starvation ketoacidosis. Immediate Jeopardy was identified but removed after the facility implemented a plan of removal and in-servicing of respiratory therapists.

The facility failed to update Resident #1's care plan to reflect current behaviors and needs, including call light use and CPAP management. Additionally, respiratory care deficiencies were found for multiple residents, including undated and unbagged oxygen tubing and CPAP equipment, placing residents at risk for infection. The call light system was inadequate for Resident #1, with call lights found on the floor and not within reach.

The complaint involved neglect of Resident #1 who was found on the floor and not immediately reported to nursing staff, resulting in delayed care and injury. The facility also failed to report the neglect incident timely to authorities. Additionally, Resident #1 eloped into an unsecured courtyard and was left outside for approximately 3 hours during a storm.

The facility failed to ensure Resident #1 was free from neglect when a Student Nurse Aide found the resident on the floor but did not notify the nurse, delaying assessment and treatment. Additionally, the facility failed to prevent Resident #1 from eloping into an unsecured courtyard during a storm and failed to timely report the neglect incident to authorities. The facility implemented corrective actions including staff in-services, door alarms, and monitoring.

The investigation was complaint-driven based on allegations of failure to provide ordered wound care and appropriate catheter care for residents, including Resident #1, #2, and #3. The complaint was substantiated with findings of missed wound care on specific dates and inadequate catheter care resulting in urethral erosion for Resident #1.

The facility failed to provide wound care services as ordered for Residents #1, #2, and #3 on multiple dates in November 2023, resulting in potential risk of infection and deterioration of wounds. Additionally, Resident #1's catheter care was inadequate, with improper catheter bag placement, unsecured catheter tubing causing urethral erosion, and application of Mupirocin cream without a physician's order.

The facility failed to ensure that call lights were within reach for 7 of 114 residents, potentially risking decreased quality of life and dignity. Additionally, the facility failed to provide consistent showers/bed baths for 1 of 23 residents reviewed for activities of daily living, risking poor personal hygiene and decline in health status.

The complaint investigation focused on Resident #1's care planning and medication management. The resident's responsible party reported no care plan meeting had occurred since admission and was unaware of the antipsychotic medication prescribed. The resident exhibited new psychosis and agitation, suspected to be related to a UTI, which was not ruled out prior to medication initiation.

The facility failed to include Resident #1's responsible party in care planning meetings, did not develop a comprehensive care plan addressing her antipsychotic medication needs, and prescribed Seroquel without adequate indications or ruling out other causes such as UTI. Resident #1 experienced behavioral issues and was hospitalized with a UTI during the medication period. The facility's policies and practices regarding psychotropic medication management and care planning were not properly followed.

The complaint investigation revealed that the facility did not provide sufficient notice to Resident #1's Guardian or the Ombudsman regarding the resident's transfer. The Guardian was informed only after the transfer had occurred and was not involved in the decision-making process. The Ombudsman did not receive timely notification of the discharge as required.

The facility failed to provide Resident #1, their responsible party, and the local ombudsman with a 30-day written notice of discharge before the resident was transferred to another long-term care facility. The Guardian and Ombudsman reported not receiving sufficient or timely notification, and the facility's policy on discharge notification was not properly followed.