Deep Creek Health & Rehabilitation

Inspectors wroteBased on interview and facility policy review, the facility failed to ensure an effective water management program was developed and implemented to prevent the growth of opportunistic waterborne pathogens, including Legionella, which had the potential to affect all residents residing in the facility. According to the Midnight Census report, dated 09/15/2025, the facility census was 89.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to maintain an effective pest control program. Specifically, observations were made of pest activity on 2 of 2 units and in the conference room, kitchen, and communal bathroom.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to secure smoking materials to ensure resident safety in accordance with the facility's smoking policy for 1 (Residents #59) of 3 residents sampled for smoking. The facility also failed to ensure an assessment was conducted to determine if a resident could safely smoke independently for 1 (Resident #72) of 3 residents sampled for smoking and failed to conduct smoking safety assessments quarterly for 1 (Resident #66) of 3 residents sampled for smoking.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow up on pharmacy recommendations for 2 (Residents #66 and Resident #98) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility's administration failed to require adherence to the facility's smoking policy or revise the policy to appropriately direct staff on ensuring residents' smoking safety. Interviews revealed the facility's prior administration directed staff that strict adherence to the supervision and smoking material storage aspects of the policy was no longer required; however, the policy was not revised accordingly. Additionally, administration failed to identify and address inconsistencies with adherence to the policy's requirement for quarterly smoking safety assessments. The failed practice affected 3 (Residents #59, #66, and #72) of 3 residents sampled for smoking.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to provide residents with advanced beneficiary notices, with enough information to make informed decisions, for 2 (Resident #45 and Resident #46) of 3 residents sampled for beneficiary notices.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASARR) was completed for 2 (Resident #66 and Resident #6) of 2 residents reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to develop a care plan to address smoking for 1 (Resident #59) of 3 residents sampled for smoking.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide incontinence care to 1 (Resident #12) of 3 sampled residents reviewed who were dependent on staff for assistance with activities of daily living (ADLs).

Inspectors wroteBased on a family interview, staff interviews, clinical record review, and review of documents, the facility's staff failed to adequately position Resident #1 on an unfamiliar piece of equipment, an egg crate mattress used as a transfer/slide device for obese residents. The facility staff also failed to provide supervision by leaving the resident's room and not leaving the bed in the lowest position. Resident #1, one (1) of Seven (7) residents in the survey sample, fell from the bed and sustained injuries.

Inspectors wroteBased on medical record review, staff interviews and facility document review the facility failed to ensure that 10 of 56 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #52, #257, #258, #255, #26, #57, #48, #7, #25 and #94.

Inspectors wroteBased on clinical record review and staff interviews, the facility's staff failed to complete a quarterly Minimum Data Set (MDS) assessment at least every 92 days for each resident.

Inspectors wroteBased on clinical record review and staff interviews, the facility's staff failed to complete the resident required discharge Minimum Data Set (MDS) assessment within the required timeframe after each discharge from the facility.

Inspectors wroteBased on review of facility documents and staff interview, the facility's staff failed to ensure a Registered Nurse was on duty for 8 consecutive hours each day

Inspectors wroteBased on observations, clinical record review, and staff interview, the facility's staff failed to maintain a resident's dignity by ensuring the bedside drainage bag fluid was concealed from view for 1 of 56 residents (Resident #14), in the survey sample.

Inspectors wroteBased on information obtained during the Resident Council Meeting, and interviews, the facility staff failed to inform residents of the location of the survey book which listed the results of the most recent surveys.

Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #34 and Resident 55) in the survey sample.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure all the required documentation including care plan goals and physician/RP (responsible party) contact information were sent with one of 56 residents; Resident #48 upon transfer to the hospital on 1/19/21.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to notify the local long term care ombudsman of an acute care transfer to the hospital for two of 56 sampled residents; Resident #48 and #52.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure the written bed hold policy was sent with one of 56 residents; Resident #48 upon transfer to the hospital on 1/19/21.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to complete a significant change MDS (Minimum Data Set) assessment for one of 56 residents; Resident #41, after being admitted to hospice services.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to inform one resident representative of care plan meetings and follow ups after conducting CP meetings.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to complete weekly wound assessments for a pressure ulcer* to the right heel that was present upon admission for one of 56 sampled residents, Resident #57. *Pressure Injury (ulcer)- A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. https://npuap.org/page/PressureInjuryStages.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility's staff failed to ensure the resident's call bell was kept within reach for 1 of 56 residents (Resident #39), in the survey sample.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that facility staff failed to appropriately store medications on one of four facility medication carts; the 400 hall medication cart.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure that the garbage disposal area was free from garbage and refuse.

Inspectors wroteBased on review of facility documents and staff interviews, the facility's staff failed to ensure two of two Certified Nurse Aides (CNA) in-service training included dementia management and resident abuse prevention training.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to evidence that all the required documentation (including care plan goals) was sent with the resident during a facility-initiated transfer to the hospital for 5 of 44 residents in the survey sample, Resident #21, 31, 22, 35, 41. 1. For Resident #21, facility staff failed to evidence that care plan goals were sent with the resident during a transfer to the hospital on 1/13/19. 2. For Resident #31, facility staff failed to evidence that care plan goals were sent with the resident during a transfer to the hospital on 1/18/19. 3. For Resident #22, facility staff failed to evidence that care plan goals were sent with the resident during a transfer to the hospital on 3/4/19. 4. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written documentation that the ombudsman was notified of a resident transfer for 8 of 44 residents in the survey sample, Resident #21, #31, #22, 35, 41, 17, 57, and 103. 1. For Resident #21, facility staff failed to provide written documentation that the Office of the State Long-Term Care Ombudsman was notified of her transfer to the hospital on 1/13/19. 2. For Resident #31, facility staff failed to provide written documentation that the Office of the State Long-Term Care Ombudsman was notified of his transfer to the hospital on 1/18/19. 3. For Resident #22, facility staff failed to provide written documentation that the Office of the State Long-Term Care Ombudsman was notified of his transfer to the hospital on 3/4/19. 4. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written notification of the bed hold policy at the time of a facility-initiated transfer for 8 of 44 residents in the survey sample, Resident #21, 31, 22, , 35, 41, 17, 57, and 103. 1. The facility staff failed to provide Resident #21 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 1/13/19. 2. The facility staff failed to provide Resident #31 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 1/18/19. 3. The facility staff failed to provide Resident #22 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 3/4/19. 4. [...]

Inspectors wrote2. Resident #104 was admitted to the facility on [DATE] with diagnoses of schizophrenia, diabetes mellitus, Non-Alzheimer's Dementia, hemiplegia and seizure disorder. The facility staff failed to provide a (Preadmission Screening and Resident Review) (PASARR) to assess the need of Resident #104 for a mental disorder or intellectual disability prior to admission. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #104 in the area of hearing, speech and vision as having no difficulty's. In the area of Cognitive Patterns this resident had a BIMS score of 3. In the area of Functional Status Activities of Daily Living (ADL'S) this resident was assessed in the areas of bed mobility, transfer, dressing, eating toilet use and personal hygiene as requiring extensive assistance of one person physical assist. A Care Plan dated 3/19/19 indicated: [...]

Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to staff a Registered Nurse (RN) for at least 8 hours a day, 7 days a week and failed to ensure the Director of Nursing (DON) worked as a supervisor/charge nurse only when the facility had a census of 60 or less.

Inspectors wroteBased on clinical record review, staff interviews, and review of the facility's policy the facility staff failed to meet the needs of the residents by collecting specimens and obtain laboratory services for 1 of 44 residents (Resident #51), in the survey sample. The facility staff failed to obtain Resident #51's monthly complete blood count ordered 6/4/18, and the facility staff failed to obtain a complete metabolic panel, thyroid stimulating hormone, hemoglobin A1C levels, magnesium, uric acid, and a lipid profile ordered every April, August and December beginning 6/4/18.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 discharged residents (Resident #38 and #94) in the survey sample. 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #38 who was discharged from skilled services with Medicare days remaining. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #94 who was discharged from skilled services with Medicare days remaining.

Inspectors wroteBased on observations, clinical record review, staff interviews, and review of the facility's policy the facility staff failed to assure Minimum Data Set (MDS) assessments accurately reflected the resident's status at the time of the assessment for 2 of 44 residents (Resident #11 and #41), in the survey sample. 1. The facility staff failed to assure Resident #11's 1/14/19, quarterly MDS assessment was accurately coded at section P0100 (Physical Restraints). 2. The facility staff failed to ensure that Resident #41's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/19 was accurately coded under Section P (Restraints and Alarms).

Inspectors wroteBased on record review, individual and staff interviews the facility staff failed to develop a care plan for seizures for one resident (Resident #27) in the survey sample of 44 residents.

Inspectors wroteBased on complaint investigations, staff interviews, facility document review, and clinical record review the facility staff failed to ensure that one (1) of 44 residents in the survey sample received treatment and care in accordance with professional standards of practice, Resident # 22. The facility staff failed to administer five consecutive doses of scheduled Ativan.

Inspectors wroteBased on a complaint investigation, clinical record review, facility document review and staff interviews the facility staff failed to ensure timely physician orders for the care of multiple pressure ulcers were obtained for 1 of 44 residents in the survey sample, Resident #106. The facility staff failed to obtain physician orders for the care of multiple pressure ulcers upon admission for Resident #106 within a timely manner.

Inspectors wroteBased on a complaint investigation, facility record review, staff interviews, resident interviews and facility document review the facility staff failed ensure 2 of 44 residents in the survey sample received their diabetic shoes in a timely manner, Resident #17 and Resident #24. 1. The facility staff failed to ensure a pair of diabetic shoes was provided to Resident #24 in a timely manner. 2. The facility staff failed to provide Resident #17 with physician ordered diabetic shoes.

Inspectors wroteBased on record review, staff interview and a complaint investigation, the facility staff failed to adequately assess and obtain pain medication for one resident (Resident #57) in the survey sample of 44 residents.

Inspectors wroteBased on record review, staff interview and a complaint investigation, the facility staff failed to have available pain medication to one resident (Resident #57) in the survey sample of 44 residents.

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to provide an assistive eating device to a resident who needed it to improve their ability to eat independently for 1 of 44 residents (Resident #11), in the survey sample. The facility staff failed to provide Resident #11 with the ordered Rocker knife during the midday meal on 4/11/19 and 4/12/19.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to maintain infection control practices during wound care observation for one of 44 residents in the survey sample, Resident #79. For Resident #79, facility staff failed to maintain infection control practices during wound care observation of his right heel pressure ulcer (1). (1) A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. [...]

Inspectors wroteBased on clinical record review, staff interview, and review of the facility's policy the facility staff failed to electronically transmit encoded and complete Minimum Data Set (MDS), data to the Centers for Medicare/Medicaid System, for 1 of 44 residents (Resident #1), in the survey sample of 44 residents. The facility's staff failed to transmit Resident #1's encoded 1/25/19, annual Minimum Data Set (MDS) assessment.