Deficiency Records for Ingleside at Rock Creek
Updated as of May 01, 2023
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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-06-09 | 2020-07-03 | 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 | 2020-01-15 | 2020-02-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-15 | 2020-02-29 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2020-01-15 | 2020-02-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-15 | 2020-02-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-15 | 2020-02-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-15 | 2020-02-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-15 | 2020-02-29 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2020-01-15 | 2020-02-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-15 | 2020-02-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-15 | 2020-02-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-01-15 | 2020-02-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-15 | 2020-02-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-15 | 2020-02-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-01-15 | 2020-02-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-02-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-14 | 2020-02-29 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2018-10-26 | 2018-12-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-26 | 2018-12-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-26 | 2018-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-26 | 2018-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-26 | 2018-12-13 | 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 | 2018-10-26 | 2018-12-13 | N |
| Keep all essential equipment working safely. | Health | 2018-10-26 | 2018-12-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-26 | 2018-12-13 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-10-26 | 2018-12-13 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-26 | 2018-12-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-10-26 | 2018-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-26 | 2018-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-26 | 2018-12-13 | N |
| 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 |
| 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 |
| 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 |
