Martin Health Center, INC

Based on observation, clinical record review, policy review and staff interview the facility failed to properly store food according to manufacturer's directions, ensure staff contain hair in hairnets when in the kitchen, and failed to ensure hot food is held at 135 degrees Fahrenheit (F) for safety. The facility reported a census of 48 residents. Findings include: The initial kitchen observation completed on 5/12/25 at 9:48 AM on the second floor kitchen revealed the following: a. One ¾ full carton of Ready Care thickened orange juice dated 4/18/25. The Manufacturer Directions on the side of the carton directed to discard 7 days after opening. b. One ¼ full bottle of Thick It Clear Advantage Thickened Water, level 2, mildly thick, dated 4/15/25. The Manufacturer Label on the bottle directed to use within 14 days after opening. During a follow up inspection of the second floor kitchen on 5/13/25 at 10:54 AM the following observations were made: a. One ¾ full carton of Ready Care thickened orange juice dated 4/18/25. The Manufacturer Directions on the side of the carton directed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review and staff interview, the facility failed to check gastronomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach and is sometimes referred to as a feeding-tube) placement prior to flushing water and administering medications down the g-tube for 1 of 1 resident observed (Resident #21). The facility identified a census of 48 residents. Findings include: Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified he rarely/never understood, he had no memory recall of current season, location of room, staff names and/or faces, or that he lived in a nursing home. The MDS reflected he had severely impaired daily decision making skills. Resident #21 had upper and lower extremity impairments on both sides of the body. The MDS listed him as dependent for care (oral care, toileting, dressing, bathing, turning in bed). The MDS included diagnoses of Parkinson's, unspecified, end stage renal disease, non…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review and staff interview the facility failed to serve the physician ordered diet for 1 of 3 residents on a carbohydrate-controlled diet (Resident #47). The facility identified a census of 48 residents. Findings include: Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified she had short/long term memory impairment with moderate impaired daily decision making. The MDS included a diagnosis of type two diabetes mellitus (DM) with diabetic polyneuropathy (a condition where multiple peripheral nerves in the body are damaged from high blood sugar levels). The MDS reflected Resident #47 received insulin injections seven days a week and hypoglycemic (blood sugar lowering) medications while a resident. An Order Review History Report electronically signed by the Provider on 4/29/25 documented the following physician orders: a. Toujeo Solostar (insulin) subcutaneous solution pen injector 300 Units (U)/Milliliter (ML) inject 16 units subcutaneously…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to complete Significant Change Minimum Data Set (MDS) assessment for 4 of 4 residents (Residents #14, #32, #35, and #37) within 14 days of identifying a significant change occurred. The facility reported a census of 46 residents. Findings include: 1. Resident #14's MDS assessment dated [DATE] indicated he didn't receive hospice care while a resident. The Hospice Certification and Plan of Care dated 4/12/24 identified Resident #14 elected to receive Hospice services. The Hospice Medicare Benefit Revocation dated 4/16/24 indicated Resident #14 choose to revoke hospice services. Resident #14's Clinical - MDS record reviewed on 7/11/24 indicated the facility completed an entry MDS assessment on 4/11/24 and a quarterly MDS assessment on 5/22/24. The review lacked documentation of a significant change MDS assessment following Resident #14's election of Hospice benefits or when he revoked his Hospice benefits.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to notify the state ombudsman as required for emergency transfers for 2 of 3 residents reviewed (Residents #2 and #8). The facility reported a census of 46 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Progress Note written on 12/24/23 at 11:12 PM reflected Resident #2 transferred to the hospital. The Progress Note on 12/25/23 at 7:06 AM listed Resident #2 admitted to the hospital. Review of the December 2023 Ombudsman notification form lacked documentation of Resident #2's discharged to the hospital on [DATE]. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 10, indicating moderately impaired cognition. Resident #8's Census listed statuses of hospital leave on the following dates: 8/30/23, 9/15/23, 12/21/23, 4/12/24, and 7/4/24. The Progress Note on 8/29/23 at 9:05 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to complete a new level I Preadmission Screening and Resident Review (PASRR) for Level I on 12/30/22 for 1 of 1 resident reviewed (Resident #26). The facility reported a census of 46 residents. Findings include: Resident #26's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety, bipolar disorder, psychotic disorder, and non-Alzheimer's disease. Review Resident #26's PASRR Level 1 Screening Outcome dated 11/30/20 reflected a PASRR Level I Determination, No Level II required. Review of the clinical chart revealed this PASRR came with Resident #26 from another facility, but the current facility failed to submit a new PASRR due to new diagnosis and medication. The Progress Notes dated 6/19/24, and 7/2/24 for Resident #26 revealed follow up psychiatric visits related to bipolar. The Pre admission Screening and Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, policy review and record review, the facility failed to provide one resident (Resident (R) 4) of 15 sampled residents, out of total sample of 46 residents, respect and dignity. Specifically, R4 was allowed to sit in, urine-soaked garments for over 90 minutes, while sitting in the dining room, during an activity and in the TV room with other residents. Findings include: Review of the undated Patients' Rights Policy revealed The resident has a right to a dignified existence, . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The record review on 06/13/23 at 4:45 PM revealed the Care Plan dated for 05/24/23, and found under the Care Plans tab in the Electronic Medical Record (EMR), did not include concerns for ADLs (Activity of Daily Living) for frequent soaking of garments. Review of R4 quarterly Minimum Data Set (MDS), with an Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and policy review, the facility failed to ensure two residents (Resident (R) 35 and 10) of 15 sample residents, out of a total of 46 sample residents, was afforded the opportunity to be included in all aspects of person-centered care planning. Findings include: Review of the facility policy titled, Care Plan Interdisciplinary Team, revised on 03/2023, read in pertinent part, Each resident's care plan shall be reviewed every 3 months or PRN (as needed) with changes in health/condition. Interdisciplinary team will meet to review with resident, resident's family/representative, and others who may be involved in the resident' care. 1. Review of R35's Face Sheet, located in Electronic Medical Record (EMR) under the Profile tab, revealed an admission date of 10/21/19 with diagnoses which included pulmonary embolism without acute coronary pulmonale, cardiovascular and coagulations. Review of R35's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 04/14/23 revealed R35's was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to ensure one of one resident (Resident (R) 4) of 15 sampled residents, out of total sample of 46 residents, had a clean and homelike environment. Specifically, housekeeping staff failed to ensure R3's room did not have a strong scent of urine. Findings include: Observation on 06/13/23 at 8:45 AM, R4's room has an odor in the sitting area and bathroom, Observation on 06/13/23 at 1:05 PM, revealed R4 in his room, there was a strong odor of urine. Interview on 06/13/23 at 12:35 PM, with the Director of Nursing (DON) who stated she was aware of the strong urine odor in R4's room. She stated they have been trying different products and continue to investigate new products that can be used. Interview on 06/13/23 at 1:00 PM, with the Household Coordinator (HHC), stated she was aware of the strong urine odor in R4's room and had been trying different products. She stated she had steam cleaned the carpet at least once per month. She indicated it was difficult to remove the odor when R4 continued to urinate on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to assist residents with Activities of Daily Living (ADL) care for one of one resident (Resident (R) 3) of 15 sampled residents, out of a total sample of 46 residents reviewed for ADL's. Specifically the facility failed to ensure R3's chin hair was removed while receiving a shower. Findings include: 1. Review of R3's Face Sheet, located in the Electronic Medical Record (EMR) under the admission record tab, revealed an admission date of 02/10/23 with medical diagnoses that included Type 2 Diabetes, Acute Diastolic Heart Failure, Reduced mobility, and Muscle Weakness. Review of R3's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an assessment reference date (ARD) of 05/19/23, revealed a Brief Interview for Mental Status score (BIMS), of 15 out of 15, indicating R3 was cognitively intact. The MDS revealed R3 required extensive physical assistance of two persons for her personal hygiene needs. Review of R3's care plan, located in the EMR under the Care Plan tab last updated 05/29/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.