Hidden Waters Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Maryland.
- Location
- 9211 Stuart Lane, Clinton, Maryland 20735
- CMS Provider Number
- 215231
- Inspections on file
- 22
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hidden Waters Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
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.
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.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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