Hidden Waters Rehabilitation and Wellness Center

In the surveyor’s words

From the most serious findings on record at Hidden Waters Rehabilitation and Wellness Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Dec 6, 2024

  Based 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. The findings include: The Center for Disease Control's (CDC) Preventing Hypothermia publication on 2/7/24, read that victims of hypothermia are often: older adults with inadequate heat. www.cdc.gov. On 12/2/24 at 1:00 PM an observation in the lobby of the facility revealed it felt cold, and residents and staff were wearing coats, hats, and gloves. During an observation of the 1st floor nursing unit on 12/2/24 at 3:45 PM it felt cold on the unit. There were large heating units located sporadically in the hallways. […]

• Immediate jeopardy, isolatedF689May 16, 2023

  Based on the review of a facility-reported incident, record review, and interviews it was determined that the facility failed to prevent a cognitively impaired resident with a history of wandering from eloping. This was evident for 1 of 6 (Resident #211) Residents reviewed for elopement risk during an annual and complaint survey. The Maryland Office of Health Care Quality (OHCQ) determined that the concern met the Federal definition of Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further elopements which met all elements of past noncompliance. The period of noncompliance began on 12/21/22 and ended on 12/25/22. […]

• Actual harm, isolatedF689Jun 5, 2025

  [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. The findings include: Review of complaint intake MD00212102 on 6/3/25 at 10:30am revealed that resident #55 ' s family alleged that the facility neglected to provide adequate supervision to the resident. This lack of supervision resulted in the resident having a fall incident. Review of resident #55 ' s medical record revealed a care plan that stated that the resident had ADL self-care performance deficit due to his/her immobility as of 7/3/2017. […]

• No harm, potential for more than minimal, widespreadF835Dec 6, 2024

  Based 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. The findings include: The Center for Disease Control's (CDC) Preventing Hypothermia publication on 2/7/24 read that victims of hypothermia are often: older adults with inadequate heat. www.cdc.gov. […]

• No harm, potential for more than minimal, widespreadF843Dec 6, 2024

  Based 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. The findings include: On 12/5/24 the Nursing Home Administrator (NHA)was asked to provide a copy of their transfer agreement. On 12/5/24 at 2:44 PM a review of the documentation provided revealed they had not included the transfer agreement. On 12/6/24 at 8:16 AM an interview with the NHA, revealed she provided the agreements with facilities in the case of an evacuation. NHA was asked to bring the transfer agreement with local hospital(s) in the event a resident needed acute care services. […]