A list of the most recent deficiencies for Regency Care of Silver Spring, LLC. 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? |
|---|---|---|---|---|
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-02-26 | 2021-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-26 | 2021-03-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-02-26 | 2021-03-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-26 | 2021-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-26 | 2021-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-26 | 2021-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-02-26 | 2021-03-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-11 | 2019-07-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-11 | 2019-07-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-11 | 2019-07-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-11 | 2019-07-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-11 | 2019-07-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-11 | 2019-07-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-18 | 2019-07-12 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-06-18 | 2019-07-12 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-18 | 2019-07-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-06-18 | 2019-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-18 | 2019-07-12 | 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 | 2019-06-18 | 2019-07-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-18 | 2019-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-18 | 2019-07-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-18 | 2019-07-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-18 | 2019-07-12 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-06-18 | 2019-07-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-18 | 2019-07-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-18 | 2019-07-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-18 | 2019-07-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-18 | 2019-07-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-16 | 2018-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-16 | 2018-06-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-16 | 2018-06-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-04-16 | 2018-06-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-04-16 | 2018-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-16 | 2018-06-25 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-04-16 | 2018-06-25 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Develop a communication plan. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-16 | 2018-06-04 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-04-16 | 2018-06-04 | N |
| Respond appropriately to all alleged violations. | Health | 2018-04-16 | 2018-06-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-04-16 | 2018-06-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-16 | 2018-06-04 | 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 | 2018-04-16 | 2018-06-04 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-04-16 | 2018-06-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-16 | 2018-06-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-04-16 | 2018-06-04 | N |
| Post nurse staffing information every day. | Health | 2018-04-16 | 2018-06-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-16 | 2018-06-04 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-04-16 | 2018-06-04 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-04-16 | 2018-06-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-16 | 2018-06-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-16 | 2018-06-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-16 | 2018-06-04 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2018-04-16 | 2018-06-04 | N |
