Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 |
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