Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hidden Waters Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Medication administration practices did not follow ordered times or accurate charting requirements. Surveyors found multiple residents with medications given and documented hours late, and observed an LPN charting medications as given that were not prepared or were documented under the wrong form, including an oral dose recorded as a rectal suppository. Surveyors also observed a narcotic signed out after administration and an inhaler charted before it was actually given by another nurse. The DON stated these behaviors were not the facility’s policy or expectation for safe medication administration.
A resident’s right to a dignified existence was not maintained when visibly soiled linens with brown stains and a strong stool odor were left partially rolled up at the bedside while the resident sat in a wheelchair and ate breakfast. The resident said this happens every morning and the linens are usually removed later, and the DON confirmed that leaving visibly soiled linens at bedside during tray service was not the expectation.
A resident was observed in the middle bed of a 3-bed room without a privacy curtain between that bed and the adjacent bed, leaving the resident not shielded from view. During an interview, the DON stated the expectation was for a privacy curtain to be present between each resident in the room.
Exposed thermostats and broken dresser doors were observed in multiple resident rooms during survey rounds. The thermostats in two rooms were missing outer protective covers with internal elements exposed, and dressers in five rooms had broken or missing door compartments. The findings were shared with the NHA and DON, and the same conditions were later observed again.
Medication administration errors were observed during med pass, including an LPN charting Aspirin as given even though it was not observed being prepared or administered, documenting oral Acetaminophen as a rectal suppository, omitting ordered Zinc sulfate and Modular Protein, and charting Fluticasone-Salmeterol as given when it was omitted. An LPN also gave Dulaglutide over an hour late and documented it after the scheduled time.
Controlled substance records and medication storage were not properly maintained for two residents. An oxycodone solution for one resident was tracked on two different narcotic books without proper transfer reconciliation, a discharged resident’s latanoprost remained in the refrigerator with a fading label, and an LPN failed to sign off an administered lacosamide dose, leaving the narcotic count inaccurate.
Breakfast Juice Portion and Type Not Followed: Staff on 2 West poured about 2 oz of juice into cups before tray delivery even though the breakfast menu called for 4 oz. A resident received apple juice despite stating a dislike for it, and another resident’s diet order called for orange juice with no documentation of a substitution, refusal, or preference change. The RDM stated the unit received enough juice and that nursing staff were to give 4 oz as ordered.
Food was not delivered to residents at an appropriate temperature on a clinical unit. A resident reported that items such as potatoes and eggs arrived cold. Although meal items tested in the kitchen met standards, the test tray sent on a portable cart to the unit did not maintain proper heat. The carts lacked external doors, and when the meal was tested on the unit, the lima beans, tater tots, and shredded barbeque pork were all below the 135-degree holding standard.
A resident with bilateral heel wounds was observed in bed with both heels resting directly on the mattress and no heel-relieving device in use. The resident reported heel discomfort and showed open areas on both heels, but the weekly skin check completed by an LPN documented no skin areas noted. The LPN later stated the resident did have heel wounds and that the form had been answered incorrectly because it was thought to refer only to new skin areas.
Infection prevention and control failures were observed when a resident’s Foley bag was found resting on the floor at the bedside and an LPN administered medications to another resident under Enhanced Barrier Precautions without cleaning hands before or after the task or wearing gloves. The resident with the Foley had orders for catheter use due to acute urinary retention and worsening function, with later diagnosis of obstructive uropathy.
Survey results were not readily accessible at the front desk, and the most recent survey findings were missing from the primary binder. The DON confirmed that the latest results were stored in a different binder on another unit, leading to incomplete and inaccessible survey information for review.
Survey results binders placed in public areas contained nine pages listing the names of 232 residents and their attending physicians, making confidential information accessible to anyone. Both the DON and NHA confirmed that this information should not have been included in the binders.
A resident was involuntarily discharged for non-payment, despite not having an outstanding bill, and was not permitted to remain in the facility while an appeal was pending. The facility was aware of the appeal through staff meetings and email correspondence but proceeded with the discharge as scheduled.
A resident who was dependent on staff for ADL care and required two-person assistance for turning was left with only one GNA during care, resulting in a fall from bed and a leg fracture. Staff interviews and documentation confirmed the resident's need for two-person assistance, but this was not provided at the time of the incident.
A resident's grievance about a missing prosthetic leg was not promptly addressed by the facility, and neither the resident nor the Ombudsman received updates or communication regarding the status or resolution of the grievance for several months.
A resident was subjected to verbal abuse by a GNA during ADL care, including inappropriate comments about bowel movements and a statement suggesting the resident should be in a hospital. The incident upset the resident, and although the GNA admitted to making the statements, the facility's investigation did not substantiate the abuse allegation and did not provide re-education on abuse prohibition to the involved staff member.
A resident sustained a facial scratch during an altercation with another resident and was transferred to the hospital for evaluation. The facility did not document when the incident was reported to the state authorities, and the DON was unable to provide evidence of timely reporting, as the relevant email confirmations had been deleted.
Facility staff did not thoroughly investigate two incidents involving alleged abuse and injury. In one case, a resident with intellectual disabilities was found with unexplained bruising, but staff interviews were inconsistent and documentation was incomplete. In another case, two residents were involved in an altercation resulting in a facial scratch, but the investigation lacked clear witness accounts, accurate documentation, and complete resident assessments. These failures were acknowledged by the DON.
Facility staff did not provide a written discharge notice or document the discharge process for a resident whose insurance was ending. The resident was verbally informed and given the option to appeal, but there was no written notification or record of discharge planning discussions in the medical record.
Facility staff did not create or update individualized care plans for three residents, resulting in one resident eloping without staff knowledge, another being discharged without a discharge care plan, and a third experiencing incontinence without a care plan in place. The DON and NHA failed to recognize and address these deficiencies, and responsible staff could not provide explanations for the omissions.
Surveyors found an unlocked and accessible room containing unorganized boxes of medications, dietary supplements, tube feeding supplies, and medical equipment, as well as unsecured contractor tools. The room, which is usually locked, was left open for contractor access, making medications and supplies accessible to residents and non-authorized personnel.
Staff failed to maintain accurate and complete medical records for two residents. One resident's MOLST form was left incomplete, lacking documentation of care preferences, while another resident's progress notes inaccurately recorded shower refusals and notifications, which did not match other staff documentation or the actual timing of events.
The facility failed to maintain a safe temperature range of 71-81°F, with room temperatures as low as 45°F, causing residents and staff to wear coats and gloves indoors. A leak in the boiler system led to inadequate heating, and the facility's evacuation plan was insufficient, lacking contracts for immediate relocation. The NHA delayed evacuation, and only a few residents were asked about their willingness to evacuate, with no resident representatives contacted.
The facility failed to manage resources effectively during a heating failure, leaving residents in cold conditions without prompt evacuation. Observations showed residents wearing extra clothing and blankets, with insufficient portable heaters. The facility's emergency preparedness was inadequate, lacking specific details in the facility assessment and emergency plan. The NHA did not actively participate in the assessment review, contributing to the deficiency.
The facility did not have a transfer agreement with hospitals certified by Medicare or Medicaid, which is necessary for the quick transfer of residents needing medical care. The NHA could not provide the agreement during a complaint survey and was unable to locate it, despite a Regional Nurse stating that one existed.
The facility did not address the needs of 103 residents with DC Medicaid in their assessment, crucial for identifying resources for care and emergencies. Approval for relocation was delayed, and the NHA did not actively review the assessment, missing the omission of these residents.
A facility failed to inform a resident's responsible party about a new medical treatment plan involving intravenous fluids due to abnormal lab results. Despite the administration of sodium chloride solution and insertion of a peripheral line, there was no documentation of notification. Interviews revealed that it was the staff's responsibility to inform the responsible party, but the facility could not provide proof of such communication.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to follow professional standards of quality for medication administration, including timely administration, accurate documentation, and adherence to established medication procedures. During the annual recertification survey, surveyors reviewed medication administration records, audit reports, staff interviews, and direct observations and identified medication administration issues for 11 residents out of 28 reviewed. The facility policy stated that medications are to be charted when given and administered within one hour before to one hour after the ordered time. For multiple residents, medications were documented as given many hours after the scheduled time, with administration and documentation times recorded well beyond the ordered time. For example, one resident’s morning medications scheduled for 7:00 AM were administered around 2:03 PM and documented at 2:04 PM, while another resident’s 7:00 AM medications were administered around 2:28 to 2:29 PM and documented at 2:29 PM. Additional residents had medications scheduled for 7:00 AM or 5:00 PM that were documented several hours late, including carvedilol, Eliquis, levetiracetam, and other routine medications. One resident also had multiple medications due at 7:00 AM that were all signed off at 11:08 AM. Surveyors also directly observed medication administration practices that did not match what was charted. One LPN prepared six medications for a resident, but then charted seven medications as given, including aspirin that was not observed being prepared during the initial setup. For another resident, an LPN crushed medications, mixed them with Liquicell from a multi-use bottle, administered them orally, and then charted an acetaminophen rectal suppository as given instead of the oral acetaminophen that was actually administered. The same observation showed a narcotic was not signed out of the narcotic count book before preparation and was signed out only after administration. For another resident, an inhaler was charted as given before it was actually administered by a different nurse, and the resident also had a late dulaglutide dose after the meal and after a late fingerstick. Staff interviews confirmed that immediate documentation after administration was the expectation, and the DON stated that the observed behaviors were not the facility’s policies or expectations for safe medication administration.
Soiled Linens Left at Bedside During Meal
Penalty
Summary
The facility failed to maintain a resident’s right to a dignified existence by leaving visibly soiled linens at the bedside during the resident’s meal. During initial observation rounds, a sheet and washcloth with brown stains and a strong odor of stool were seen partially rolled up and positioned toward the end of the bed while the resident was sitting in a wheelchair at bedside with the bedside table partially across the bed. The resident, a bilateral above-the-knee amputee, stated that they clean themselves every morning and leave the linens there for staff to collect, and said the linens were still there when the aide came to get the breakfast tray. The resident reported this happens every morning and that the linens are usually moved around 9 a.m. or 10 a.m. When the findings were shared with the DON and NHA, the DON stated that leaving visibly soiled linens at bedside, even if tray distribution or pickup is in progress, was not the expectation.
Missing Privacy Curtain Between Beds in Shared Room
Penalty
Summary
The facility failed to ensure residents were not in public view and failed to provide a privacy curtain to prevent exposure of resident body parts. During initial observation rounds, a surveyor observed resident #10 lying in the middle bed of a 3-bed room, with the bed positioned parallel to the bed on the right and perpendicular to the bed on the left near the door. At that time, there was no privacy curtain between resident #10 in Bed B and the resident occupying Bed A. During an interview later that day, the DON stated that the expectation was for a privacy curtain to be present between each resident in the 3-occupant rooms.
Exposed Thermostats and Broken Dressers in Resident Rooms
Penalty
Summary
The facility failed to ensure the safety of the resident room environment by not limiting the presence of potential hazards in 5 of 26 resident rooms observed during the annual survey. During initial observation rounds, wall-mounted thermostats in rooms 234 and 237 were observed without outer protective covers, with internal elements exposed. In addition, resident dressers in rooms 227, 229, 234, 235, and 237 were observed with broken or missing door compartments. These conditions were shared with the NHA and DON during the entrance conference, and the same exposed thermostats and broken or missing dresser doors were again observed during follow-up rounds.
Medication administration errors and documentation discrepancies
Penalty
Summary
Medication administration errors were observed for 6 of 26 opportunities reviewed, resulting in a medication error rate of 23.08%. During observation of medication pass for resident #76, an LPN prepared six medications totaling seven tablets and confirmed seven tablets in the cup, but later charted Aspirin 81 mg as given even though it was not observed being prepared or administered during the initial setup. When questioned, the LPN first repeated that seven pills had been given and then stated, "I did give it," before removing an Aspirin bottle from the standard medication drawer. During medication administration for resident #9, an LPN crushed and administered Acetaminophen 325 mg, 2 tablets orally, but documented it as a suppository given rectally. The same resident’s Zinc sulfate 220 mg capsule was omitted, and the ordered Modular Protein 30 mL with 120 mL water/beverage was also omitted despite the staff member using Liquacell 5 mL to mix with the crushed oral medications. During medication administration for resident #57, an LPN charted Fluticasone-Salmeterol 100-50 mcg/act aerosol powder as given even though it was omitted during the initial administration, and Dulaglutide 1.5 mg subcutaneously scheduled for 8:00 AM was not given on time and was charted as given at 9:14 AM.
Controlled Substance Reconciliation and Medication Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled, stored, and reconciled for controlled substances and discharged residents. For Resident #119, the narcotic book for Cart #2 showed oxycodone 5 mg/5 mL solution with 30 mL on hand, but the medication was not present in the locked narcotic box. Staff stated it had been transferred to Cart #1, yet the narcotic sheet did not document the transfer in the medication transferred section. A separate narcotic book entry on Cart #1 also listed the same resident’s oxycodone as active, and the medication was observed sealed and unused in the locked medication box. The resident had been admitted to one room and then transferred to another room, but the controlled medication remained tracked across two carts without proper reconciliation. For Resident #230, a fading and partially illegible latanoprost ophthalmic solution label was observed in the medication refrigerator even though staff confirmed the resident was no longer in the facility. Staff did not know who reconciled medications for discharged residents, and the DON stated the expectation was to remove the medications and return them to Pharmacy per protocol. In a separate observation, lacosamide 150 mg tablets were found in a resident’s narcotic box on the 3 [NAME] unit, and the narcotic count log showed 12 tablets remaining even though a dose had been administered. The nurse who gave the medication stated she forgot to sign it off, resulting in an inaccurate narcotic count.
Breakfast Juice Portion and Type Not Followed
Penalty
Summary
The facility failed to ensure residents received the menu-specified type and required portion size of juice during breakfast meal service on 2 West. During observation of the meal service, a GNA was seen placing clear plastic cups on top of the meal cart and pouring approximately 2 ounces of apple juice into each of about 15 cups before tray delivery, even though the posted breakfast menu called for 4 ounces of juice with breakfast. Resident #106 was observed with two clear plastic cups of apple juice on the breakfast tray, and each cup contained approximately 2 ounces of juice. When interviewed at that time, the resident stated, "I don't like apple juice." Record review showed Resident #130 was ordered to receive 4 ounces of orange juice with breakfast, but there was no documentation of a substitution, refusal, or change in resident preference. During interview, the GNA stated the juice was poured into cups before trays were served to make sure there was enough for everyone. The Regional Dietary Manager stated the unit received enough juice for each resident, that 6-ounce cups were sent to 2 West, and that nursing staff were to administer 4 ounces of juice as ordered to each resident; the manager also stated the cups were not sent in error on the date of the breakfast service.
Food Delivered Below Required Temperature
Penalty
Summary
Food was not delivered to residents at an appropriate and palatable temperature on the 3 [NAME] clinical unit. During a resident interview, Resident #92 stated that food was okay but items such as potatoes and eggs arrived cold. On 12/11/2025, the facility’s lunch meal was temperature-tested in the kitchen, and the internal temperatures of the food items on the preparation trays met professional standards. However, the test tray sent to the 3 [NAME] clinical unit did not meet the standard of practice for internal temperatures of the meat and vegetables. At 12:15 PM, the regional dietary director tested the preparation trays and recorded temperatures including regular barbeque pork at 179 degrees, grilled cheese sandwich at 145.9 degrees, tater tots at 140.7 degrees, lima beans at 177 degrees, macaroni noodles at 166.8 degrees, brown gravy at 158 degrees, pureed mashed potatoes at 186 degrees, pureed lima beans at 157.7 degrees, and shredded pork at 177 degrees. The three portable food carts for the unit left the kitchen between 12:25 PM and 12:30 PM, and the test tray was placed on the third cart. At 12:35 PM, the surveyor observed that all three carts lacked external doors, which prevented additional protection from heat loss while traveling through the facility, the elevator, and the clinical unit. When the meal was tested on the unit at 12:45 PM, the lima beans were 124.0 degrees, the tater tots were 113 degrees, and the shredded barbeque pork was 120 degrees, all below the 135-degree holding temperature standard.
Inaccurate Skin Assessment Documentation
Penalty
Summary
Facility staff failed to maintain accurate medical record documentation for a resident with bilateral heel wounds. During observation, the resident was found lying supine in bed with socks on both feet resting directly on the mattress and no pillow or heel-relieving device in use. The resident complained of wounds and discomfort to both heels, stated they had not been instructed to elevate the heels off the bed, and showed open areas on both heels measuring approximately 3 cm x 2 cm on the left heel and 2 cm x 1.5 cm on the right heel. Record review showed that after surveyor intervention, a wound care assessment and treatment recommendations were completed, and the care plan reflected interventions for the bilateral heels. However, the weekly skin check completed by the resident’s primary nurse documented that there were no skin areas noted and was signed as completed, despite the resident having bilateral heel wounds. During interview, the nurse stated the form was used for the weekly skin assessment and acknowledged that the resident had heel wounds but that the form had been answered incorrectly because the nurse thought it referred only to new skin areas.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections under its infection prevention and control program. During initial observation rounds, a resident with a urinary catheter/Foley had the catheter bag observed resting on the floor at the bedside. The resident’s record showed physician orders for the Foley catheter, which had been placed for acute urinary retention and worsening function, and the resident was later diagnosed with obstructive uropathy. The facility also failed to follow enhanced barrier precautions during medication administration for another resident. A staff member entered the resident’s room with prepared medications, where a sign indicated that everyone must clean their hands before entering and when leaving the room. The staff member administered the medications at the bedside without performing hand hygiene before or after administration and without wearing protective gloves.
Survey Results Not Readily Accessible and Incomplete at Reception
Penalty
Summary
The facility failed to ensure that survey results were readily accessible and that the most recent survey results were available for review. Upon entry, a surveyor requested the latest survey results from the front desk receptionist, who was unable to locate the survey binder in its usual location. The Director of Nursing (DON) later provided the binder, explaining that it had been removed by the Regional Director of Clinical Operations and not returned to its designated spot. Review of the binder revealed that it contained results from a previous survey but did not include the most recent survey completed several months prior. The DON confirmed the omission and acknowledged that the most recent results were located in a different binder on another unit.
Failure to Protect Resident Information in Publicly Accessible Binders
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' personal and medical information. During a review of survey results binders, it was found that both binders contained nine pages listing the names of 232 residents along with their attending physicians. These binders were accessible in public areas, including the front lobby and a unit referred to as one West, making the information available for anyone to review. The Director of Nursing confirmed that the resident and physician lists should not have been included in the survey results binders, as these are accessible to the public. The Nursing Home Administrator also confirmed the inappropriate placement of this information.
Failure to Permit Resident to Remain During Pending Discharge Appeal and Inappropriate Discharge Reason
Penalty
Summary
The facility failed to have an appropriate reason for the involuntary discharge of a resident and did not allow the resident to remain in the facility while an appeal of the discharge was pending. The discharge was initiated on the grounds of non-payment, specifically citing that Medicaid would not pay for the resident's stay due to exceeding the allowable number of Leave of Absence (LOA) days. However, both the Business Office Manager and the Director of Nursing confirmed that the resident did not have an outstanding bill at the time of discharge. Documentation and interviews revealed that the resident had filed an appeal against the discharge with the assistance of the Ombudsman, and the facility was made aware of this appeal through email correspondence and daily department meetings prior to the discharge date. Despite being informed of the pending appeal, the facility proceeded with the discharge as scheduled. The resident was discharged and had to stay at a relative's home, as their own residence was uninhabitable due to a fire. The discharge summary and notes confirmed the discharge plans, and meeting notes indicated that the appeal was discussed among staff. No additional information was provided at the time of exit to justify the discharge or to indicate that the appeal process had been properly considered or followed.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as being totally dependent on staff for activities of daily living (ADL) care and bed mobility, experienced a fall resulting in harm. The resident's care plan and Kardex indicated a need for two-person assistance for toileting hygiene and for being rolled from left to right. Despite these documented requirements, a single GNA provided ADL care and attempted to turn the resident alone, during which the resident slid off the bed and fell to the floor. The incident was witnessed by the GNA, who had raised the bed to waist height and asked the resident to use the upper bed rails to assist with turning. The resident continued to roll toward the left side, with their legs sliding off the bed, and the GNA was unable to prevent the fall due to the resident's size. The GNA called for help, and the RN Unit Manager responded to assess the resident, who complained of pain in both legs. The resident was subsequently transferred to the hospital, where a fracture to the left leg was diagnosed. Interviews with facility staff, including the DON, RN Unit Manager, and MDS Coordinator, confirmed that the resident was known to require two-person assistance for turning and hygiene. The GNA involved in the incident acknowledged being re-educated on proper procedures following the event. The facility's failure to provide the required level of supervision and assistance directly led to the resident's fall and injury.
Failure to Promptly Resolve and Communicate Grievance Regarding Missing Prosthetic Leg
Penalty
Summary
The facility failed to promptly resolve a resident's grievance regarding a missing prosthetic leg and did not keep the resident informed about the progress toward resolution. The resident reported the missing prosthetic leg to the facility in January, but there was no documentation in the medical record indicating that the facility had misplaced the prosthetic leg or had taken steps to address the grievance. The Ombudsman became involved after the resident received no updates from the facility and contacted the facility multiple times without receiving any information or solutions regarding the missing prosthetic leg. Interviews confirmed that the facility was aware of the missing prosthetic leg since an evacuation event in November, but no efforts were made to reimburse or replace the prosthetic leg until the resident returned from medical treatment several months later. Throughout this period, the resident and the Ombudsman did not receive updates or communication from the facility about the status of the grievance or any actions being taken to resolve it.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A facility failed to protect a resident from verbal abuse by a staff member during the provision of activities of daily living (ADL) care. The incident involved a Geriatric Nursing Assistant (GNA) who made inappropriate comments regarding the resident's bowel movements and further told the resident that they should be in a hospital rather than the facility. The resident was upset by these statements, and the incident was reported by the resident's family. The resident had a care plan in place for psychosocial well-being, which included encouragement for communication. The facility conducted an internal investigation and determined the allegation of verbal abuse to be unsubstantiated, despite the GNA admitting to making the upsetting statements. The Director of Nursing (DON) confirmed that the GNA did not receive re-education on abuse prohibition, although other nursing staff did. The DON also acknowledged that the GNA admitted to the statements but believed there was no intent to harm and that adequate care was provided after the incident. The surveyor noted that the determination of verbal abuse is based on the resident's perception, and in this case, the resident felt verbally abused.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner as required. Specifically, a review of facility documents and staff interviews revealed that an incident occurred in which one resident sustained a facial scratch during an altercation with another resident, resulting in the injured resident being transferred to the hospital emergency department for further evaluation. The facility's investigation documented the date and time of the incident but did not include documentation of when the incident was reported to the Office of Health Care Quality (OHCQ) or when the final report was sent. When asked, the Director of Nursing was unable to provide email confirmation of the report submission, stating that the relevant emails had been permanently deleted and were no longer available.
Failure to Thoroughly Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate two separate incidents involving alleged abuse and injury of unknown origin. In the first case, a resident with intellectual disabilities and physical impairments was found with new bruising around the right upper eyelid. The facility's investigation concluded the injury was accidental, based on the resident's nonverbal cues, but review of staff interviews revealed inconsistencies. Multiple staff assigned to the resident during the relevant period denied caring for the resident, despite schedule records indicating otherwise. Additionally, the unit manager interviewed herself as part of the investigation, and there was no clear process for verifying the accuracy of staff statements. In the second incident, a resident-to-resident altercation resulted in one resident sustaining a facial scratch and being sent to the emergency room. The facility's investigation lacked documentation of which staff first responded to the incident, and all witness statements indicated that no staff were present during the altercation. The statements also contained conflicting dates, and there was no documentation from the staff who heard the initial noise or separated the residents. Furthermore, abuse questionnaire forms used in the investigation did not include resident names or the names of interviewers, and skin assessment forms were incomplete, missing dates and staff identifiers. The scratch sustained by the resident was not documented on the skin assessment forms, and the medical record lacked details on the size and depth of the wound. Both incidents demonstrate failures in the facility's investigative process, including incomplete and inaccurate documentation, lack of thorough staff interviews, and insufficient record-keeping regarding resident assessments and incident response. These deficiencies were acknowledged by the DON during discussions with surveyors.
Failure to Provide Written Discharge Notice and Documentation
Penalty
Summary
Facility staff failed to provide a resident with written notification of a pending discharge and did not ensure that the discharge was properly documented in the medical record. Record review showed that the resident was discharged, but there was no written notice of discharge, nor was there documentation of discussions with the resident regarding discharge planning, the resident's input, or the reason for discharge. The only documentation present was a progress note indicating the discharge had occurred. Interviews with staff revealed that while the social worker designee discussed discharge planning with the resident, who was uncertain about post-discharge arrangements, no written 30-day discharge notice was issued. The business office manager confirmed that the resident was only verbally informed of the discharge and given the option to appeal, which was described as the facility's standard practice when a resident's insurance was ending. The nursing home administrator acknowledged the concern during review.
Failure to Develop and Implement Comprehensive Resident Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, resident-centered care plans for multiple residents, as evidenced by three specific cases. In one instance, a resident with no cognitive impairment but significant physical limitations was able to leave the facility premises without staff knowledge, ultimately being found at a nearby shopping center parking lot. Despite a prior physician's order requiring supervision for leave of absence and an MDS assessment indicating the resident was wheelchair-bound, the facility did not recognize the incident as an elopement, did not update the elopement risk assessment appropriately, and failed to create a care plan or interventions to prevent recurrence. Both the DON and NHA acknowledged not recognizing the event as an elopement. In another case, a resident was discharged from the facility without a discharge care plan, and the responsible social worker could not provide a rationale for this omission. Additionally, a third resident, who was frequently incontinent of bowel and bladder according to MDS assessments and a bowel elimination pattern document, had no care plan addressing incontinence, despite complaints of malodor and lack of ADL care. The DON confirmed the absence of an incontinence care plan for this resident. These findings demonstrate a pattern of failure to develop and implement individualized care plans based on residents' assessed needs.
Unsecured Storage of Medications and Medical Supplies
Penalty
Summary
Facility staff failed to ensure that stock medications and medical supplies were securely stored, as required by professional standards. During a random tour of one unit, surveyors observed an open and accessible room containing numerous unorganized boxes filled with various medications, including Vitamin D, Aspirin, Ferrous Sulfate, Zinc, Acetaminophen, and several dietary supplements, as well as cases of Jevity tube feeding. The room also contained medical supplies such as glucose test strips and hypodermic safety needles. The room was fully accessible to residents and contained unsecured contractor equipment, including a ladder and large spools of wire. Interviews with facility staff and contractors revealed that the room had been unlocked since the morning to allow contractor access and remained open throughout the day. The central supply employee confirmed that the room is usually locked but was left open for the contractors. The Nursing Home Administrator was shown the unsecured medications and supplies during the survey, and the issue was discussed with her during the survey and at exit.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for two residents. For one resident, a review of the closed medical record revealed that the Medical Orders for Life-Sustaining Treatment (MOLST) form was incomplete, as the front page did not indicate the resident's wishes regarding life-sustaining care. The certified registered nurse practitioner (CRNP) responsible for completing the form acknowledged during an interview that the first page had not been filled out after discussing care preferences with the resident. For another resident, progress notes written by the staff developer included late entries documenting that the resident had refused showers, received education, and that notifications were made to the resident representative and physician. However, a review of the geriatric nursing assistant (GNA) documentation showed no record of a shower refusal, but rather that a bed bath was given. The staff developer later clarified that while the refusals were based on shower sheets, the education and notifications did not occur on the dates documented in the progress notes, resulting in inaccurate recordkeeping. The director of nursing agreed that the progress notes did not accurately reflect the events that occurred.
Failure to Maintain Safe Temperature and Inadequate Evacuation Plan
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature range of 71-81 degrees Fahrenheit, as required, across all three floors. Observations revealed that residents and staff were wearing coats, hats, and gloves indoors due to the cold temperatures. Specific instances included a resident on the first floor who was lying in bed with a sweatshirt and extra blanket, reporting feeling cold, and another resident on the second floor who also reported being cold since their admission before Thanksgiving. Temperature readings taken by surveyors showed that room temperatures ranged from 45 to 69.3 degrees Fahrenheit, significantly below the required range. The issue began on November 30th when a leak in the boiler system caused the heat to go out. Although portable heaters were installed, they were insufficient to maintain adequate temperatures throughout the facility. The facility's temperature logs indicated that temperatures were only being taken on each floor, not in individual rooms, which contributed to the oversight of the severity of the situation. Interviews with staff revealed that there were no blankets available, and extra fitted sheets were used instead. The Director of Nursing (DON) and Nursing Home Administrator (NHA) failed to adequately assess the residents' willingness to evacuate, as only a few residents were asked, and no resident representatives were contacted. The facility's evacuation plan was inadequate, lacking contracts with other locations for immediate evacuation and failing to secure a nearby place for emergency relocation. The NHA delayed the evacuation process, and only 11 residents were evacuated by the time of the interview. The facility also faced delays in relocating residents due to insurance and Medicaid approval issues, as they had not set up provisions for an emergency evacuation plan. These failures led to the declaration of a state of immediate jeopardy on December 2nd.
Removal Plan
- Residents in rooms number 247, 117 and 335 were moved to a warmer area of the facility.
- Assessments of current residents completed by regional and divisional teams to assure residents had no signs and symptoms of vascular changes related to temperatures.
- The Executive Director will educate all current staff to organization Emergency Preparedness Plan, Relocation Plan, Extreme Cold Temperature Protocol, Temperature monitoring of facility, temperature monitoring of residents, and HVAC mediation plan, Notification of change to residents, physicians, and resident representatives.
- We have relocated approximately 50 residents while repairs to our heating system have been made. We now feel we can maintain proper temperatures throughout the facility.
- Remaining residents will be located in rooms that have reached the range of 71-81 degrees Fahrenheit. Current resident temperatures will be monitored hourly and documented on the unit census sheet by Unit Managers. Facility environmental temperatures will be monitored hourly and documented on a temperature log by the Maintenance Director. If it is found that we are still experiencing temperature issues we will look to relocate our remaining residents.
- Executive Director to review audits daily to assure temperatures of facility and residents remain within acceptable temperature parameters.
Inadequate Emergency Preparedness and Resource Management
Penalty
Summary
The facility failed to effectively manage its resources to ensure the safety of residents when the primary heat source was lost during winter. Observations revealed that both residents and staff were wearing coats, hats, and gloves due to the cold conditions. Portable heating units were insufficiently distributed, leaving some residents without adequate warmth. For instance, one resident was found in bed with a sweatshirt and extra blanket, reporting feeling cold, while another resident was also cold but had no extra blankets. The facility did not evacuate residents promptly, despite the heating failure being discovered on November 30, 2024, and only began evacuating 36 hours later. The facility's emergency preparedness was inadequate, as evidenced by the lack of a comprehensive facility assessment that included all resident populations and necessary resources for emergencies. The assessment failed to provide specific information about contracts or agreements with third parties for emergency services and equipment. Additionally, the facility's All Hazards Risk Analysis and Emergency/Disaster Plan lacked facility-specific details, which were supposed to be included by the interdisciplinary team. Interviews with the Nursing Home Administrator (NHA) revealed a lack of active participation in the review and update of the facility assessment. The NHA admitted to not reading the entire assessment, particularly the sections on emergency preparedness. The facility is part of a larger organization, and the NHA indicated that corporate was responsible for the updated assessment. The Regional Nursing Home Administrator expected the NHA to be involved in the assessment process, but this expectation was not met, contributing to the deficiency.
Failure to Provide Transfer Agreement with Hospitals
Penalty
Summary
The facility failed to have a transfer agreement with at least one or more hospitals certified by Medicare or Medicaid, which is necessary to ensure residents can be moved quickly to a hospital when they require medical care. During a complaint survey, the Nursing Home Administrator (NHA) was unable to provide a copy of the transfer agreement when requested on 12/5/24. Instead, the NHA provided agreements related to evacuation procedures. On 12/6/24, the NHA admitted to not being able to locate a transfer agreement and was in the process of contacting the corporate office to check if one was on file. During the exit conference, a Regional Nurse mentioned that the facility had a transfer agreement but was also unable to locate it.
Failure to Address DC Medicaid Residents in Facility Assessment
Penalty
Summary
The facility failed to adequately address the specific resources needed for their resident population, particularly those with DC Medicaid, in their facility-wide assessment. This assessment is crucial for evaluating the resident population and identifying necessary resources for care and services. During a review of the facility assessment, it was found that the needs of 103 residents with DC Medicaid were not considered, especially in the context of an emergency evacuation. These residents are unique because they do not have Medicaid in the state where they are temporarily residing, and not all nursing homes accept this payer source. Interviews revealed that the facility was waiting for approval from DC Medicaid to relocate these residents to facilities that did not accept DC Medicaid. Although approval was eventually received, the evacuation could not occur immediately, as additional time was needed to find suitable placements for the residents. The Nursing Home Administrator admitted to not actively participating in the review of the facility assessment for 2024 and failed to recognize the omission of these residents. Additionally, the sections for Other and All Hazards Risk Analysis and Emergency/Disaster Plan were not reviewed to ensure all necessary resources were included in the event of an emergency.
Failure to Notify Responsible Party of New Treatment Plan
Penalty
Summary
The facility failed to inform the responsible party of a resident about a new medical treatment plan, which was identified during a complaint revisit. The resident, who was admitted with multiple diagnoses including cognitive communication deficit and dysphagia, had a physician's progress note documenting a history of dementia. On a visit, the responsible party was informed by a staff member about the administration of intravenous fluids due to abnormal lab results, which they had not been previously notified about. The responsible party confirmed that they were not contacted regarding the new treatment orders. A review of nursing progress notes revealed that a peripheral line was inserted, and sodium chloride intravenous solution was administered to the resident, but there was no documentation to support that the responsible party was notified of this new medical treatment. During interviews, the Director of Nursing explained that it is the facility staff's responsibility to contact the resident's responsible party about lab requests or new treatment orders. However, the facility was unable to provide proof of notification to the responsible party regarding the new treatment plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,044 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Pineview | 0.2 mi | ★★★★★ | 14 | 0 |
| Autumn Lake Healthcare At Bradford Oaks | 1 mi | ★★★★★ | 8 | 0 |
| Forestville Rehabilitation And Wellness Center | 5.9 mi | ★★★★★ | 44 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 6.2 mi | ★★★★★ | 35 | 0 |
| Serenity Rehabilitation And Health Center Llc | 7.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.