Hidden Waters Rehabilitation and Wellness Center

Inspectors wroteBased on resident record reviews, staff interviews, and facility record reviews, it was determined that the facility failed to adhere to professional standards of quality of established clinical practices, physician orders, or facility policies regarding medication administration. This was evident for 11 residents (Resident # 11, #17, #3, #62, #119, #232, #76, #9, #57, #50, and #8 ) out of 28 residents reviewed for medications during the annual recertification survey. Facilities must ensure that all care and services, including medication administration, adhere to accepted standards of clinical practice. This is often interpreted through established guidelines like the six rights of medication administration: right patient; right medication; right dose; right route; right time; and right documentation. [...]

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain the resident right to a dignified existence, by leaving visibly soiled linens on the resident's bedside during their meal while at bedside. This was evident for 1 (resident #122) out of 1 resident observed for Resident Rights during the annual survey.

Inspectors wroteBased on observations, record reviews and staff interviews, it was determined that the facility failed to ensure residents are not in public view and to provide a privacy curtain to prevent exposure of resident body parts. This was evident for 1 (resident #10) out of 1 observed without a privacy curtain between bed A and bed B in a 3-bed room during the annual survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure the safety of the resident room environment by not limiting the presence of potential hazards. This was evident for 5 (rooms 227, 229, 234, 235, and 237) of 26 resident rooms observed during the annual survey.

Inspectors wroteBased on observations, record reviews and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician orders for 6 of 26 opportunities reviewed. This deficient practice resulted in residents receiving medications contrary to physician orders and a medication error rate of 23.08%.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to maintain proper records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and, failed to properly dispose of medications of a discharged resident. This was evident for 2 (residents #119 and #230) out of 2 residents reviewed for medication labeling and storage review during the annual survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the menu-specified type and required portion size of juice during the breakfast meal service. Specifically, residents on 2 [NAME] unit were provided with less than the required 4 ounces of juice, and at least one resident (#106) received a juice type inconsistent with their dietary order. This failure had the potential to negatively affect 2 west residents' nutritional intake, preferences, and compliance with physician-ordered diets.

Inspectors wroteBased on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents on the 3 [NAME] clinical unit who eat food prepared by the facility.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility staff failed to maintain medical records for a resident in accordance with accepted professional standards and practices to contain accurate documentation. This was evident for 1 (resident #15) out of 1 resident reviewed for accurate identifiable information during the annual survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections based on an established infection prevention and control program. This was evident for 2 (residents #158 and #9) out of 46 residents observed during initial review for Infection Prevention & Control during the annual survey.

Inspectors wroteBased on observation, review of survey results binders, and interview, the facility failed to 1) have readily accessible the survey results and 2) have the results from the last survey available for review. This was found on entry into the building and of 1of 2 survey result binders.

Inspectors wroteBased on a review of survey results binders, and interviews, it was determined that the facility failed to protect the privacy of residents' information. This was found evident in 2 of 2 survey results binders.

Inspectors wroteBased on record review and interviews, the facility failed to have an appropriate reason to involuntarily discharge a resident and failed to permit that resident to remain in the facility, and not discharge, while the appeal for discharge was pending. This was found evident in 1 (Resident #21) out of 1 Residents reviewed for involuntary discharges.

Inspectors wrote[NAME] ' s example: Harm Based on record review and interview, it was determined that the facility failed to ensure that adequate supervision to prevent accidents/hazards was provided 1) during care which resulted in a fall causing harm to Resident #55. This was evident for 1 of 38 residents reviewed for complaints.

Inspectors wroteBased on medical record review and interview, the facility failed to make prompt efforts to resolve a resident's grievance and also failed to keep the resident appropriately apprised of the progress toward resolution. This was evident for 1 (#25) of 55 residents reviewed in a complaint survey.

Inspectors wroteBased on record review and staff interview; it was determined that the facility failed to protect their residents from verbal abuse from a facility staff member. This was evident for 1 (#46) of 55 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility documents and staff interview it was determined the facility failed to report an allegation of abuse immediately but not later than 2 hours after an allegation was made. This was evident for 1 (#21) of 19 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff and the review of a facility reported incident (FRI), it was determined that the facility staff failed to 1. thoroughly investigate an injury (bruising) of unknown origin and 2. failed to thoroughly investigate allegations of abuse. This was evident during the review of 2 of 19 facility reported incidents. Residents (#20 and #21)

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to notify a resident in writing of a pending discharge and failed to ensure that the discharge was documented in the medical record. This was evident for 1 (#27) of 1 resident reviewed for discharges.

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to develop resident-centered comprehensive care plans for their residents. This was evident for 3 (#8, #27, and #53) of 38 residents reviewed for complaints.

Inspectors wroteBased on observation during tour and interview with facility staff, it was determined that the facility staff failed to ensure that the facility stock medications and supplies were maintained in a secure fashion. This was found evident during one of the random tours completed during the complaint survey on 1 of 3 units.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 (#47) of 17 facility reported incidents reviewed and 1 (#35) of 38 residents reviewed for complaints.

Inspectors wroteBased on observation, record review and staff interview, it was determined that the facility failed to maintain a safe temperature of 71-81 degrees Fahrenheit (F). This was evident for 3 of 3 floors in the facility.

Inspectors wroteBased on observations, record review, and interview it was determined that the facility failed to 1) use their resources appropriately to ensure the safety of their residents when they lost their primary heat source in the winter and 2) ensure that their facility assessment included all populations of residents, and the resources needed in the case of an emergency. This was evident during the survey and had the potential to affect all residents.

Inspectors wroteBased on record review and interview it was determined that the facility failed to have a transfer agreement. This was evident during the complaint survey and had the potential to affect all residents.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to address the specific resources needed for their resident population. This was evident 103 and of 233 residents.

Inspectors wroteBased on interviews and medical record reviews, it was determined that the facility failed to inform the residents responsible party of a new medical treatment plan. This deficient practice was evident during a complaint revisit.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure the facility is maintained in a safe and homelike environment. This was evident for 3 out of 3 floors.

Inspectors wroteBased on observations during an environmental tour, it was determined that the facility failed to maintain a safe, sanitary, comfortable, and functional environment for the residents, staff, and visitors.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to have adequate ventilation in resident bathrooms. This was evident in 13 resident bathrooms observed on the 2nd floor, 2 [NAME] of the facility.

Inspectors wroteBased on record review, staff, and Resident Representative interview, it was determined that the facility failed to ensure that resident concerns were addressed in a timely manner. This was found to be true for 1 of 1 facility Concern Forms and 6 of 6 Resident Council Meeting Minutes reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to document accurate assessments for Resident (#189, #125, #137, and #144) on the MDS. This was evident for 6 of 164 residents selected for review during the survey process.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to review and revise a Resident's care plan after an assessment. This was evident for 3 of 9 (Resident #215, #56, and #49) Residents reviewed for care planning on an annual and complaint survey.

Inspectors wrote3. A review of Resident #209's clinical record revealed that the resident used a continuous positive airway pressure (CPAP) device prior to admission. There is no mention of the CPAP in the admission assessments. The resident was noted to have a diagnosis of sleep apnea. The most common treatment for sleep apnea is CPAP. A review of the resident's progress notes revealed numerous mentions that the resident has had trouble falling/staying asleep. A review of the monthly pharmacy reviews revealed that the pharmacist did not determine that there were any irregularities with the medicinal regimen. Further review of the clinical record revealed the resident has had numerous medications ordered and administered either for insomnia or for another diagnosis but with the thought it would help the resident to sleep. The medications were: [...]

Inspectors wroteBased on observations, interviews and record review it was determined that the facility failed: 1) to have water easily assessable for residents to promote hydration (#56, #3 and #188) 2) The facility staff failed to notify the provider of a noted weight loss (#42). This was found evident of 3 of 5 reviewed residents reviewed for hydration and 1 of 10 residents reviewed for nutrition while on an annual and complaint survey. 1. On 4/17/23 at 1:03 PM, the surveyor observed Resident #56 without a bedside table or cup of water. 2. Further observation revealed Resident #56's roommate, Resident #3, had a bedside table but had no water cup at his/her bedside. On 4/17/23 at 1:05 PM, the surveyor interviewed Geriatric Nursing Assistant (GNA) in training Staff #71. [...]

Inspectors wroteBased on observation and interview with facility staff it was determined that the facility failed to ensure pureed bread was of appropriate consistency for residents who require a puree diet. This was evident for 1 of 4 pureed meal items being served for lunch at the facility on 5/11/23.

Inspectors wroteBased on observations of the facility's kitchen, review of kitchen records and interviews of dietary staff, it was determined that the facility 1.) failed to ensure the temperature of food items maintained an acceptable serving temperature and failed to ensure timely delivery of a meal, 2.) failed to ensure the dishwashing system was properly functioning and maintaining appropriate temperatures for rinsing and washing of dishes, and 3.) failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. These deficient practices have the potential to affect all residents.

Inspectors wroteBased on residents' bedroom observation it was determined that multiple occupancy bedrooms did not provide the minimum space per bed as required.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility staff failed to ensure that handrails were firmly secured to corridor walls. This was evident for 3 of 3 floors reviewed for secured handrails.

Inspectors wroteBased on tours of the facility, observation, and staff interview it was determined that the facility staff failed to ensure they had a working pest control program. This was evident for all three floors of the facility.

Inspectors wroteBased on medical record review and interviews, it was determined the facility staff failed to include a resident's representative and/or guardian in the care of a resident (Resident #201, #657, #56) This was evident for 3 of 164 residents reviewed during an annual survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility staff failed to ensure that a resident deemed incapable of making decisions had a responsible party or a surrogate decision maker to act on their behalf (#167). This was evident for 1 out of 164 residents in the survey sample.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure that the residents had access to the call bell system and failed to ensure a resident's choice of bathing preferences were honored This was evident for 3 (#118, #203 and #209) out of 164 residents reviewed during an annual and complaint survey.

Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility.

Inspectors wroteBased on record review and interview it was determined that the facility failed to offer to formulate an advanced directive. This was found evident in 2 (Resident #126 and #137) out of 13 Residents reviewed for advanced directives during the annual survey.

Inspectors wroteBased on observation and medical record review, it was determined that the facility staff failed to protect the personal privacy and confidentiality of medical records. This was evident for 1 (2 West) of 5 nursing stations.

Inspectors wroteBased on observation, medical record review, and interview of facility staff it was determined the facility failed to comprehensively and accurately assess the diagnoses of a resident. This was evident for 2 out of 164 (Resident #9 and #203) residents reviewed during an annual and complaint survey.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to develop a comprehensive care plan for residents. This was found to be evident for 2 (# 203 and # 738) out of 9 residents reviewed for comprehensive care plans.

Inspectors wroteBased on resident interview and clinical record review it was determined that the facility staff failed to maintain an activity program that meets a resident's needs (#126). This was evident for 1 out of 164 residents in the survey sample.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined that the facility failed to 1.) follow up and ensure ophthalmology services recommendations were obtained for Resident #125, and 2.) failed to make an ophthalmology appointment for Resident #49. This was evident for 2 of 9 residents reviewed for Sensory Communication during the annual survey.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to provide appropriate oxygen therapy equipment. This was found to be evident for 1 (# 738) out of 1 resident observed on oxygen therapy.

Inspectors wroteBased on a review of the resident record the facility failed to provide dialysis services for Resident # 487 on Wednesday 7/27/22 as ordered by the physician. This was evident for 1 out of 1 person reviewed for dialysis.

Inspectors wroteBased on a review of the medical record and interview with staff it was determined that the facility failed to ensure that the physician addressed a resident's significant weight loss. This was evident for 1 (#42) of 164 residents reviewed for weight loss.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to post accurate, up-to-date, staffing information prior to the start of each shift. This was found evident on 2 of 2 random observations.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure that a resident medication was administered as ordered as evidenced by delayed administration of insulin. This was evident for 1 (# 226) out of 1 resident reviewed for sliding scale insulin coverage administration.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure medications were stored properly. This was evident for: 1) 2 out of 2 Storage Rooms and 2) 4 out of 5 Medication Carts inspected for proper storage.

Inspectors wroteBased on observation and clinical record review it was determined that the facility staff failed to ensure residents received needed dental care (#42). This was evident for 1 out of the 10 residents reviewed for dental needs during and annual and complaint survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to accurately follow dietary menus. This was found evident in 3 out of 10 (#96, #25 & #188) Residents reviewed for nutrition during an annual and complaint survey.

Inspectors wroteBased on observation and interview with facility staff it was determined the facility failed to maintain cleanliness of the garbage and waste disposal area.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to keep accurate medical records. This was evident in 1 of 164 (Resident #96, #672, #203, and #484) Resident's records reviewed during an annual and complaint survey.

Inspectors wroteBased on interviews and observations it was determined that the facility failed to maintain adequate conditions of a bed. This was evident during 3 of 3 observations.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide appropriate bedroom furniture for a resident. This was evident on 2 of 2 observations.

Inspectors wroteBased on medical Records and staff interview, it was determined that the facility staff failed to secure personal property for Resident #36 and Resident #232, while both residents were in the Hospital. This was evident for 2 out of 42 Residents investigated during the survey process. The Findings Include: 1. On 03/12/19 around 09:38 AM, Resident #32 was interviewed about the loss of personal property. Resident #32 uses a motorized wheelchair to ambulate on and off the unit. Upon return to the facility on 2/18/19, the facility was unable to locate the Resident's chair. During an interview with the Environmental Service Director (EVS) on 03/14/19 around 11:05 AM, the EVS explained the process for storing resident's belongings: when a resident goes out to the hospital, nursing bags up the Resident's property and generates a property form that goes with the property. [...]

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to clarify an unclear order for blood pressure medication for Resident #184. This was evident for 1 of 42 residents investigated during the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the residents or resident's representatives were notified in writing of reason residents are being transferred out of the facility to an acute care hospital. This was found to be evident for 3 out of 3 residents records reviewed for hospitalization involving Resident #238, R#161, and R#145 reviewed during the investigative portion of the survey process.

Inspectors wroteBased on record review and interview with Director of Nursing , the facility failed to notify in writing to responsible party and resident on why resident was transferred to the hospital and the bed hold policy. This was evident for 2 out of 4 residents transferred to the hospital.

Inspectors wroteBased on medical record review and interviews it was determined the facility failed to ensure a medical device was removed as recommended for Resident #154. This was evident for 1 of 42 residents reviewed during the survey.

Inspectors wroteBased on record review, the facility failed to provide orders for catheter care. This was evident for 1 out of 1 records reviewed for urinary catheters.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to label a medication when opened. This was evident for 1 out of 6 medication carts observed during the survey process.

Inspectors wroteBased on resident bedroom observation it was determined that all multiple occupancy bedrooms did not provide the minimum space per bed as required.