Deficiency Records for Ingleside at Rock Creek
Updated as of October 01, 2018
This is not the most recent data for Ingleside at Rock Creek. For the most recent information, click here.
A list of the most recent deficiencies for Ingleside at Rock Creek. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet the legal definition of a skilled nursing facility or nursing facility. | Health | 2018-05-11 | 2018-05-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-02-16 | 2018-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-02-16 | 2018-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-16 | 2018-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-21 | 2018-05-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-02-21 | 2018-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-21 | 2018-05-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Develop a communication plan. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-16 | 2018-05-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-16 | 2018-05-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-02-16 | 2018-05-08 | N |
| Respond appropriately to all alleged violations. | Health | 2018-02-16 | 2018-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-16 | 2018-05-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-02-16 | 2018-05-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-16 | 2018-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-16 | 2018-05-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-02-16 | 2018-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-16 | 2018-05-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-02-16 | 2018-05-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-02-16 | 2018-05-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-16 | 2018-05-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-02-16 | 2018-05-08 | N |
| Provide or obtain dental services for each resident. | Health | 2018-02-16 | 2018-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-16 | 2018-05-08 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-02-16 | 2018-05-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-02-16 | 2018-05-08 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-02-16 | 2018-05-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-02-16 | 2018-05-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-02-16 | 2018-05-08 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-02-16 | 2018-05-08 | N |
| Provide timely notification to the resident before transfer or discharge. | Health | 2017-10-24 | 2017-11-27 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-10-24 | 2017-11-27 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-04-05 | 2017-05-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-04-05 | 2017-05-16 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-03-20 | 2017-05-11 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2017-03-20 | 2017-05-11 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-03-20 | 2017-05-11 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-20 | 2017-05-11 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-03-20 | 2017-05-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-03-20 | 2017-05-11 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-03-20 | 2017-05-11 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-20 | 2017-05-11 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2017-03-20 | 2017-05-11 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-03-20 | 2017-05-11 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-20 | 2017-05-11 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-03-20 | 2017-05-11 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-20 | 2017-05-11 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-03-20 | 2017-05-11 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-20 | 2017-05-11 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-20 | 2017-05-11 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-03-20 | 2017-05-11 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-20 | 2017-05-11 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-20 | 2017-05-11 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2017-03-20 | 2017-05-11 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-20 | 2017-05-11 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-10-14 | 2016-11-14 | Y |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-06-24 | 2016-07-15 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-06-24 | 2016-07-15 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-06-24 | 2016-07-15 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-06-24 | 2016-07-15 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-06-24 | 2016-07-15 | N |
| Try to resolve each resident's complaints quickly. | Health | 2016-05-27 | 2016-07-01 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-05-27 | 2016-07-01 | N |
| Provide housekeeping and maintenance services. | Health | 2016-05-27 | 2016-07-01 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-05-27 | 2016-07-01 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-05-27 | 2016-07-01 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-05-27 | 2016-07-01 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-05-27 | 2016-07-01 | N |
| Keep all essential equipment working safely. | Health | 2016-05-27 | 2016-07-01 | N |
