Marine Creek Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Marine Creek Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Jun 28, 2024

  Based on interview and record review, the facility failed to ensure residents who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice for one (Resident #1) of eight residents reviewed for tracheostomy care. The facility failed to use the recommended amount of pressure (maximum of 25 cmH2O) per manufacturer to inflate Resident #1's tracheostomy tube cuff, which led to chronic over inflation and caused remodeling of the residents T1 and T2 vertebra and swallowing difficulty that likely caused starvation ketoacidosis (metabolic state after prolonged deprivation of glucose as primary source of energy). An Immediate Jeopardy (IJ) was identified on [DATE]. […]

• Immediate jeopardy, isolatedF600Apr 14, 2024

  Based on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. […]

• Immediate jeopardy, isolatedF607Apr 14, 2024

  Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 residents (Residents #1) reviewed for abuse and neglect. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. […]

• Immediate jeopardy, isolatedF689Apr 14, 2024

  Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 of 3 residents (Residents #1) reviewed for supervision. The facility failed to ensure Resident #1, who had severe cognitive impairment and resided on the secure unit, received adequate supervision to prevent her from wandering into the facility's enclosed courtyard without staff knowledge and being left outside for approximately 3 hours while it was raining. The facility failed to ensure the door that led to the enclosed courtyard was locked or supervised, when the door's locking mechanism lost power during the storm. The noncompliance was identified as past non-compliance. […]

• Actual harm, isolatedF600Sep 3, 2025

  Based on observations, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 2 (Resident #45 and Resident #23) of 2 residents reviewed for abuse, in that: On 08/29/2025, the facility failed to ensure that Resident #45 was not punched in the face by Resident #23, resulting in injury to the face.This failure resulted in injuries to Resident #45.Resident #45Record review of a face sheet dated 09/03/2025 revealed Resident #45 was [AGE] years old and was admitted on [DATE] with a primary diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, and other pertinent diagnoses including cognitive communication… […]