Inspection Reports for Martin Coast Center for Rehabilitation and Healthcare
9555 SE Federal Hwy, Hobe Sound, FL 33455, United States, FL, 33455
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 12, 2025, showed no deficiencies. Earlier inspections had a mix of findings, with some citations related primarily to staffing standards and staff training issues. Prior reports noted deficiencies involving staff in-service training, documentation, resident care rights, and training on do not resuscitate orders. Complaint investigations during this period were unsubstantiated or found no deficiencies. The inspection history suggests improvement over time, with recent inspections consistently free of deficiencies.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
18 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 12, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2013 to 2025 with deficiency history and inspection statuses.
Findings
The facility has undergone numerous inspections including standard, complaint, change of ownership, and monitoring visits. Deficiencies were cited, corrected, or not found across different inspections, with the most recent inspections showing no deficiencies.
Report Facts
Inspections on page: 23
Inspection Report
Complaint
Deficiencies: 0
Date: Aug 12, 2025
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 12
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, care planning, infection control, nutrition, environment, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to dignity and self-determination, inadequate care planning participation, insufficient assistance with activities of daily living, improper respiratory care assessments, failure to follow approved menus, unsanitary food handling, inadequate infection control practices, and provision of inappropriate mattresses.
Deficiencies (12)
Failure to honor residents' right to a dignified existence, self-determination, communication, and to exercise rights, including failure to provide timely meals and respectful communication.
Failure to promote and facilitate resident self-determination through support of resident choice, including failure to provide showers per resident preferences.
Failure to provide housekeeping and maintenance services to maintain a clean, safe, and homelike environment, including damaged walls, furniture, stained curtains, and mold in shower rooms.
Failure to ensure resident participation in care planning meetings and development of care plans, including failure to invite resident to meetings and lack of documentation of resident's decision-making capacity.
Failure to provide assistance with grooming, including hair washing and nail care, for residents dependent on staff.
Failure to assess lung sounds and vital signs pre and post nebulizer treatments for residents receiving respiratory treatments.
Failure to provide medically-related pain management as ordered, including failure to remove and replace lidocaine patch daily as ordered.
Failure to provide sufficient and appropriate social services to meet resident needs, including advocacy, grievance resolution, legal assistance, and transition planning.
Failure to follow approved menu and notify residents of menu changes, including serving non-fried chicken wings instead of golden fried chicken and incorrect portion sizes.
Failure to procure food from approved sources and store, prepare, and serve food in a sanitary manner, including improper food temperatures and unlabeled food items.
Failure to ensure appropriate use of personal protective equipment (PPE) during care involving tracheostomy and feeding tubes, and failure to implement timely contact isolation for a resident with C. difficile infection.
Failure to provide an appropriate mattress that supports the resident and functions properly, resulting in resident resting on bed frame and non-functioning bed controls.
Report Facts
Residents observed in dining room: 18
BIMS score: 5
BIMS score: 14
BIMS score: 15
Fall risk score: 23
Weight of chicken wings portion: 4.5
Weight of mechanically altered chicken portion: 4.2
Resident weight: 189
Mattress weight support: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Unit Manager | Responded to Resident #8 about meal timing and failed to address resident's hunger |
| Staff G | Certified Nursing Assistant (CNA) | Interacted with Resident #83 during attempts to stand and failed to allow standing |
| Staff I | Certified Nursing Assistant (CNA) | Assisted Resident #83 to walk with assistance |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed about shower and hair washing assistance for Resident #28 |
| Staff K | Licensed Practical Nurse (LPN) | Administered nebulizer treatments without proper assessments and failed to use PPE properly |
| Staff L | Licensed Practical Nurse (LPN) | Administered nebulizer treatment without pre/post assessment of lung sounds and vitals |
| Staff M | Unit Clerk | Described mattress assignment process for residents |
| Staff N | Licensed Practical Nurse (LPN) | Administered nebulizer treatment without lung sound assessment |
| Dietary Manager | Acknowledged menu substitution and food temperature issues | |
| Dietary Aide Staff B | Described preparation of chicken and plated meals | |
| Social Services Director | Unable to locate documentation of resident involvement in care planning and social service needs | |
| Administrator | Informed of concerns regarding resident care planning and social services | |
| Maintenance Director | Acknowledged mattress issues and lack of audit documentation | |
| Wound Care Nurse | Unaware of mattress concerns for Resident #309 | |
| Infection Control Preventionist | Confirmed PPE use expectations and timing of contact isolation |
Inspection Report
Deficiencies: 0
Date: Oct 12, 2024
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Inspection Report
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the release of medical records requested on behalf of residents' legal representatives.
Findings
The facility failed to develop a protocol for releasing medical records requested by residents' legal representatives, failed to verify the legitimacy of such requests, and failed to release records for 1 of 2 sampled residents. There was no tracking mechanism to verify if requests were completed, and staff sent a request to the wrong person with no evidence of approval, denial, or fulfillment.
Deficiencies (1)
Failure to develop a protocol for the release of medical records requested on behalf of the resident's legal representative, failure to verify if the request was legitimate, and failure to release the resident's records for 1 of 2 sampled residents.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided clarification on medical records requests and explained staff inexperience and lack of written policy |
Inspection Report
Deficiencies: 1
Date: Jun 24, 2024
Visit Reason
One Class 3 deficiency related to staffing standards.
Findings
One Class 3 deficiency related to staffing standards.
Deficiencies (1)
Tag A0078 — STAFFING STANDARDS - STAFF
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted based on a complaint investigation regarding the nursing staff's failure to accurately document wound care treatment orders and the provision of wound care for two sampled residents.
Complaint Details
The complaint investigation revealed that the nursing staff did not document wound care treatment orders or the provision of wound care accurately for Resident #1 and Resident #4. The wound care nurse admitted to performing treatment without writing the order initially, which was later corrected. The Director of Nursing confirmed inaccurate documentation practices.
Findings
The investigation found that nursing staff did not properly document wound care treatment orders or the provision of wound care for Resident #1 and Resident #4, contrary to facility policy. The wound care nurse and floor nurses failed to document treatment orders and administration accurately, resulting in incomplete medical records.
Deficiencies (1)
Nursing staff failed to accurately document wound care treatment orders and the provision of wound care for 2 of 2 sampled residents.
Report Facts
Residents affected: 2
Dates wound care not provided: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed nursing staff did not document wound care accurately. | |
| Wound Care Nurse | Interviewed and verified failure to document treatment order and provision of wound care for Resident #4. |
Inspection Report
Complaint
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Routine
Deficiencies: 9
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, and administrative oversight.
Findings
The facility was found deficient in multiple areas including maintaining a safe and clean environment, timely reporting and investigation of abuse and misappropriation allegations, proper PASARR screening, appropriate catheter care, nutritional assessment and intervention, food safety and sanitation, complete medical record documentation, and quality assurance committee participation.
Deficiencies (9)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, safe, clean, comfortable home-like environment, including issues with air conditioning units, damaged furniture, dirty floors, and pest migration gaps.
Failed to timely report 2 of 2 credible allegations of misappropriation of property to the State Agency and Law Enforcement affecting 2 residents.
Failed to investigate 1 of 2 credible allegations of misappropriation of property affecting 1 resident.
Failed to complete a required Level II PASARR screening for 1 resident with documented serious mental illness and dementia.
Failed to provide appropriate care and services for 1 resident with an indwelling urinary catheter diagnosed with two urinary tract infections, including improper catheter care and drainage bag placement.
Failed to reassess and implement nutritional interventions in a timely manner after significant weight loss and continued decline for 1 resident.
Failed to prepare, serve, and store foods under sanitary conditions, including improper dishwasher temperatures and sanitizer levels, wet nesting of equipment, rust and food residue on slicer, use of non-cleanable milk crates, and mold in ice machine.
Failed to ensure a complete medical record for 1 resident, lacking documentation and follow-up of a nurse-witnessed choking incident.
Failed to ensure documented evidence of participation of 2 of 3 mandated members (Medical Director and Administrator or leadership) at monthly Quality Assessment and Assurance meetings.
Report Facts
Weight loss percentage: 6.18
Weight loss percentage: 12.92
Temperature: 100
Temperature: 110
Chlorine sanitizer concentration: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #365 | Resident | Reported bed bath water was cold and staff response. |
| Staff A | Certified Nursing Assistant | Provided bed bath with cold water to Resident #365. |
| Regional Maintenance Director | Explained hot water was turned off for flushing and mixing valve issues. | |
| Social Services Director | Involved in reporting and follow-up of misappropriation allegations. | |
| Resident #51 | Resident | Reported misappropriation of property by previous facility manager. |
| Resident #76 | Resident | Reported missing credit cards and personal items. |
| Speech Language Pathologist | Did not follow up with evaluation after choking incident reported by nurse. | |
| Staff D | Licensed Practical Nurse | Reported choking incident but did not document or refer for evaluation. |
| Director of Nursing | Acknowledged concerns with catheter care and lack of documentation. | |
| Food Service Manager | Acknowledged concerns with dishwasher operation and kitchen sanitation. | |
| Administrator | Acknowledged lack of reporting and documentation in abuse and misappropriation cases. | |
| Assistant Nursing Home Administrator | Discussed Quality Assessment and Assurance meeting attendance issues. | |
| Nursing Home Administrator | Discussed Quality Assessment and Assurance meeting attendance issues. |
Inspection Report
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with regulations regarding the timely conveyance of resident funds and final accounting upon discharge, eviction, or death.
Findings
The facility failed to convey resident funds and provide a final accounting within 30 days to the residents or their estates for 2 of 3 sampled residents. Specifically, refunds owed to Resident #1 and Resident #2 were delayed, with Resident #1's refund amount varying between $992.84 and $2,436.38 and Resident #2 owed $463.20 with only a partial refund of $17.00 issued.
Deficiencies (1)
Failed to convey within 30 days the resident's funds and a final accounting of those funds to the residents or their estates for 2 of 3 sampled residents.
Report Facts
Days since Resident #1 expired: 315
Days since Resident #2 expired: 195
Resident #1 refund amount: 992.84
Resident #2 refund amount owed: 463.2
Resident #2 partial refund: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding resident refunds and accounting discrepancies |
| Director of Accounts Receivable | Director of Accounts Receivable | Interviewed regarding accounts payable and receivable and refund processing |
Inspection Report
Complaint
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Routine
Census: 112
Deficiencies: 8
Date: Apr 21, 2022
Visit Reason
Routine inspection of Martin Coast Center for Rehabilitation and Healthcare to assess compliance with regulatory requirements including resident care, medication management, nutrition, infection control, and staffing.
Findings
The facility was found deficient in multiple areas including failure to provide showers per resident preference, incomplete care plans for residents with elopement risk and fall risk, improper catheter care, inaccurate medication reconciliation, inadequate menu variety and meal preparation, failure to post nurse staffing information timely, unsafe food storage and handling practices, and failure to timely notify residents/families of COVID-19 outbreak.
Deficiencies (8)
Failed to provide showers per resident/family preferences and care plan for Resident #18.
Failed to develop and implement complete care plans for residents with high elopement risk and exit seeking behaviors, and failed to ensure fall risk assessments were completed for Resident #42.
Failed to provide appropriate catheter care for Resident #73, including improper anchoring of catheter tubing and tubing lying on the floor.
Failed to post nurse staffing information every day at the beginning of each shift for 6 of 6 days observed.
Failed to ensure accurate reconciliation of controlled medications for 6 of 6 sampled residents, with discrepancies between medication monitoring/control records and medication administration records.
Failed to provide a menu with a variety of protein choices for breakfast meals and failed to prepare meals according to approved recipes and menus, affecting many residents.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including improper food temperatures, contamination risks, and unsafe reheating practices.
Failed to timely inform residents/representatives/families of confirmed COVID-19 cases during outbreak on 04/14/22 involving 7 residents.
Report Facts
Residents affected: 7
Census: 112
Shower frequency: 3
Fall risk score: 21
Medication discrepancies: 6
Days nurse staffing info not posted: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Nurse Unit Manager | Acknowledged care plan and fall risk assessment deficiencies for Resident #18 and Resident #42 |
| Staff K | Certified Nursing Assistant | Acknowledged failure to secure chair alarm for Resident #42 |
| Staff O | Licensed Practical Nurse | Confirmed medication administration documentation discrepancies |
| Staff P | Licensed Practical Nurse | Confirmed medication administration documentation discrepancies |
| Staff N | Certified Nursing Assistant | Observed improper catheter care for Resident #73 |
| Assistant Director of Nursing | Interviewed regarding COVID-19 reporting and nurse staffing posting | |
| Infection Preventionist | Registered Nurse | Interviewed regarding COVID-19 outbreak reporting |
| Staff C | Cook | Acknowledged recipe changes without dietitian approval |
| Assistant Kitchen Manager | Interviewed about menu approval and food preparation issues | |
| Administrator | Interviewed about menu changes and food presentation | |
| Director of Nursing | Acknowledged medication reconciliation discrepancies and nurse staffing posting issues |
Inspection Report
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
No deficiencies noted during this monitor inspection.
Findings
No deficiencies noted during this monitor inspection.
Inspection Report
Deficiencies: 0
Date: Aug 17, 2021
Visit Reason
No deficiencies noted during this standard inspection.
Findings
No deficiencies noted during this standard inspection.
Inspection Report
Complaint
Deficiencies: 0
Date: Mar 30, 2021
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Deficiencies: 1
Date: Jun 26, 2019
Visit Reason
One Class 4 deficiency related to staff in-service training.
Findings
One Class 4 deficiency related to staff in-service training.
Deficiencies (1)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Inspection Report
Deficiencies: 3
Date: Jul 12, 2017
Visit Reason
Three Class 3 deficiencies related to staff in-service training, do not resuscitate orders training, and staff records.
Findings
Three Class 3 deficiencies related to staff in-service training, do not resuscitate orders training, and staff records.
Deficiencies (3)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0161 — RECORDS - STAFF
Inspection Report
Complaint
Deficiencies: 4
Date: Apr 7, 2017
Visit Reason
Five deficiencies: three Class 4 and two Class 3 related to training, documentation, monitoring, records, and background screening.
Findings
Five deficiencies: three Class 4 and two Class 3 related to training, documentation, monitoring, records, and background screening.
Deficiencies (4)
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Tag A0160 — RECORDS - FACILITY
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Complaint
Deficiencies: 1
Date: Jun 21, 2016
Visit Reason
One Class 3 deficiency related to resident care rights and facility procedures.
Findings
One Class 3 deficiency related to resident care rights and facility procedures.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Complaint
Deficiencies: 0
Date: Sep 15, 2015
Visit Reason
No deficiencies noted during this complaint and change of ownership inspections.
Findings
No deficiencies noted during this complaint and change of ownership inspections.
Inspection Report
Deficiencies: 2
Date: Aug 11, 2015
Visit Reason
Two Class 3 deficiencies related to staff in-service training and do not resuscitate orders training.
Findings
Two Class 3 deficiencies related to staff in-service training and do not resuscitate orders training.
Deficiencies (2)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Inspection Report
Deficiencies: 2
Date: Oct 16, 2013
Visit Reason
Two Class 3 deficiencies related to resident care rights and medication assistance with self-administration.
Findings
Two Class 3 deficiencies related to resident care rights and medication assistance with self-administration.
Deficiencies (2)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Viewing
Loading inspection reports...
