Waters of Martinsville, The

In the surveyor’s words

From the most serious findings on record at Waters of Martinsville, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 18, 2022

  Based on interview and record review, the facility failed to ensure staff followed a resident's plan of care for transfers, staff did not perform tasks outside of their scope of practice, and therapy trained appropriate staff which resulted in a systemic failure and a residents fall with bilateral hip fractures for 1 of 5 residents reviewed for accidents. (Resident B) The Immediate Jeopardy began on 1/18/22 when the facility failed to ensure the resident was safely transferred by qualified staff which resulted in the resident being lowered to the ground. On 1/19/22, the resident began to experience pain and a mobile x-ray was performed at the facility which revealed a broken left hip. […]

• Actual harm, isolatedF689Apr 16, 2025

  A. Based on interview and record review, the facility failed to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a resident sustaining fractures of the wrist and hand and hospitalization for decreased mobility in lower extremities. (Resident B) B. Based on interview and record review, the facility failed to ensure a resident with an assessed behavior of wandering and a high risk of elopement was provided treatment and services to prevent an elopement which resulted in the resident going through an unlocked door and getting outside without staff knowledge for 1 of 3 residents reviewed for elopement. (Resident C) Findings include: A1. […]

• Actual harm, isolatedF686Aug 2, 2024

  Based on observation, interview, and record review, the facility failed to prevent the development and worsening of facility acquired pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. This deficient practice resulted in worsening and possible infection of an unstageable pressure ulcer and the development of a Stage III pressure ulcer. (Resident 34, Resident 5) Findings include: 1. On [DATE] at 2:06 p.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, overactive bladder, and diabetes mellitus. The Braden Scale for Predicting Pressure Ulcer, dated [DATE] at 7:52 a.m., indicated the resident was a mild risk for developing a pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was served in a safe and sanitary manner for 2 of 2 kitchen observations. Hairnets were not worn while preparing food, the dishwashing room was dirty, and expired foods were not discarded. Findings include:1. During a tour of the kitchen on 1/29/26 from 7:40 a.m. until 8:05 a.m., the following was observed.- The Activity Director and the Social Service Director were working in the kitchen, preparing meal trays, without wearing a hair net. At that time, the Social Service Director indicated they should have put on hair nets before working in the kitchen. […]

• No harm, potential for more than minimal, widespreadF812Oct 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 1 of 3 kitchen observations. Hair was not covered, food was not labeled or discarded by manufacturer's use by date, floors and other surfaces required cleaning, and a scoop was kept in dry storage goods. These had the potential to affect 52 of 53 residents residing in the facility. (Dietary Aide 2)Findings include:During an observation of the kitchen on 10/22/25 from 12:20 p.m. to 12:50 p.m., the following was observed.-Dietary Aide 2 was observed in and around the food preparation areas. […]