Atlantic Coast Rehab & Health

In the surveyor’s words

From the most serious findings on record at Atlantic Coast Rehab & Health, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 11, 2026

  Based on interviews, record reviews and a review of pertinent facility documentation, it was determined that the facility failed to a) ensure that a resident was protected from alleged abuse by a Certified Nursing Assistant (CNA) #1, and b) failed to implement facility's abuse policy when they became aware of an allegation that CNA #1 pushed the resident knocking them to the floor on 12/11/25. According to an undated document titled reference 12/11/25, which the facility provided to the surveyor, on 12/12/25, the facility administration reviewed video footage and statements from CNA #1 and LPN #1; and after the review, the Interdisciplinary Team (IDT) agreed to obtain formal statements about the incident from both Residents #1 and #2. […]

• No harm, potential for more than minimal, patternF584Jun 25, 2026

  C #2683542Based on observations and interviews, the facility failed to maintain a clean, safe, and comfortable homelike environment by ensuring the floors and resident care equipment were free of debris, food residue, and tube feeding formula for two residents (Resident (R) 13 and R15). Additionally, exit doors on the high side of each wing were observed with visible gaps either along the bottom or sides, in need of weather stripping or door sweeps. These failures had the potential to diminish residents' quality of life and compromise the overall living environment.Findings include: During an observation on 06/22/26 at 1:25 PM, the floor in the room of R13 was observed with debris and multiple areas of food spillage and splatters across the floor. […]

• No harm, potential for more than minimal, patternF628Jun 25, 2026

  Based on record review, interviews, and facility policy review, the facility failed to provide residents and their resident representatives (RR) written notices of transfer with all required information following emergent hospital transfers for two of four residents (Resident (R) 74 and R133) reviewed for hospitalization out of 30 sampled residents This failure placed residents and their RRs at risk of not being informed of the reason for the transfer, the transfer location, and their right to appeal the transfer, including how to file an appeal.Findings include: 1. Review of R74's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R74 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF756Jun 25, 2026

  Based on record review and interviews, the facility failed to ensure documented physician acknowledgment and timely response to Medication Regimen Reviews (MRRs) for three of five residents (Resident (R) 4, R13, and R14) reviewed for unnecessary medications out of a sample of 30 residents. Additionally, the facility failed to implement an effective system to monitor, track, and prevent the recurrence of medication administration errors identified on the MRRs. These failures resulted in R13 and R14 continuing to receive medications outside of prescribed parameters and had the potential to result in unnecessary medication use, adverse drug effects, and increased risk of oversedation for all residents.Findings include: 1. […]

• No harm, potential for more than minimal, patternF695Feb 14, 2025

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice by not storing nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) and Bilevel positive airway pressure device (BiPap- a breathing device that helps a person breathe easier) equipment in bags which resulted in environmental exposure for 3 of 5 residents reviewed for oxygen use (Resident #22, 34, 89) . […]