Inspection visit
Fire Safety inspection
Citations
25 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0741GeneralS&S Dpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0100GeneralS&S Dpotential for harm
Meet other general requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223GeneralS&S Dpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0226GeneralS&S Dpotential for harm
Have horizontal exits used in accordance with safety requirements.
- 0281GeneralS&S Dpotential for harm
Install proper backup exit lighting.
- 0293GeneralS&S Dpotential for harm
Have properly located and lighted "Exit" signs.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362GeneralS&S Fpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0364GeneralS&S Dpotential for harm
Install properly constructed windows in hallway walls or doors.
- 0500GeneralS&S Dpotential for harm
Meet other general requirements that are deficient.
- 0712GeneralS&S Dpotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Epotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0781GeneralS&S Dpotential for harm
Have restrictions on the use of portable space heaters.
- 0909GeneralS&S Dpotential for harm
Ensure gas and vacuum piping is labeled.
- 0918GeneralS&S Epotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920GeneralS&S Dpotential for harm
Ensure proper usage of power strips and extension cords.
- 0921GeneralS&S Epotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the May 16, 2023 survey of Hidden Waters Rehabilitation and Wellness Center?
This was a inspection survey of Hidden Waters Rehabilitation and Wellness Center on May 16, 2023. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Hidden Waters Rehabilitation and Wellness Center on May 16, 2023?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.