Ingleside at Rock Creek

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 21 sampled residents, the facility staff failed to adequately monitor a resident with a history of Dementia and prior exit-seeking behaviors. Subsequently, the resident eloped from the third-floor unit located in Building One and was found wandering outside of the facility near a busy intersection. (Resident #24) Due to these failures, an Immediate Jeopardy (IJ) was identified on March 26, 2025, at 1:09 PM. The facility provided a plan of action to address the immediacy on March 26, 2025, at 6:43 PM and it was accepted. Review of the facility's plan determined that the immediate jeopardy was Past Non-Compliance due to corrections being completed prior to the start of the recertification date. The facility immediate jeoparyd existed until Janury 29, 2025.

Inspectors wroteBased on record review and staff interviews for two (2) of 21 sampled residents, the facility staff failed to develop and implement a person-centered care plan, and develop a discharge plan, for two residents. (Residents #8, #35.)

Inspectors wroteBased on observations, record review staff interviews and resident interviews, for seven (7) of 21 sampled residents, the facility staff failed to have documented evidence that the Interdisciplinary Team (IDT) reviewed or revised care plans or conducted care plan conferences after each Minimum Data Set (MDS) assessments. (Residents' #1, #7 #8, #13 #15, #18, and, #20).

Inspectors wroteBased on record reviews and staff interviews, the attending physician failed to document in the resident's medical record a response, if applicable, to address the pharmacist identified irregularities for five (5) of 21 sampled residents. Residents' #18, #2, #8, #4 and #15.

Inspectors wroteBased on record review and staff interview for one (1) of 21 sampled residents, the facility's staff failed to immediately inform the administrative staff or resident's physician that the resident accidentally spilled hot coffee on her chest and developed a blister on her chest several hours later. (Resident #1)

Inspectors wroteBased on record review and staff interviews for one (1) of 21 sampled residents, facility staff failed to report the results of an investigation of a resident elopement to the State Survey Agency within five (5) working days. (Resident #24)

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to report the results of all investigations to the State Survey Agency, within 5 working days of the incident for three (3) of 21 sampled investigations. (Residents' #1, #18, and #24)

Inspectors wroteBased on record review and staff interview, for one (1) of 21 sampled residents, facility staff failed to complete a Level I PASARR (Preadmission Screening and Resident Review) to determine if the resident had or may have had an MD (mental disability), ID (intellectual disability), or related condition for a resident that remained in the facility as a long-term care resident for longer than 30 days. Resident #15.

Inspectors wroteBased on observation record reviews and staff interviews, for one (1) of 21 sampled residents, the physician failed to review a resident's total program of care, including medications and treatments, after five physician visits. Subsequently, a resident's blood pressure medication order was not clarified and corrected from 11/04/24 to 02/05/25.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 21 sampled residents, the facility staff failed to ensure that all licensed nurses had the specific competencies, and skill sets necessary to care for residents' needs. Resident #4.

Inspectors wroteBased on observation and staff interview for one (1) of 21 sampled residents, facility staff failed to ensure that a resident's medication was properly labeled, as evidenced by an opened multi-dose bottle of a liquid supplement that was undated inside the resident's medication drawer. (Resident #4)

Inspectors wroteBased on observations and staff interview, facility staff failed to prepare, and distribute foods under sanitary condition, as evidenced by one (1) of one (1) open, and expired eyewash solution in the east-wing kitchen, one (1) of one (1) dishwashing machine in the east-wing kitchen that was leaking, one (1) of one (1) empty paper towel dispenser in the east-wing kitchen, one (1) of one (1) broken paper towel dispenser in the west-wing kitchen, one (1) of one (1) expired eyewash solution in the west-wing kitchen, no handwashing soap for one (1) of one (1) handwashing sink in the west-wing kitchen, dust and/or foreign substance accumulation in one (1) of one (1) walk-in refrigerator, and four (4) of four (4) ready-to-eat food packages that were inappropriately stored in the walk-in refrigerator.

Inspectors wroteBased on a review of the facility's records and a staff interview, the facility failed to comply with the State Regulation (22B DCMR section 3211.5) for daily staffing ratios, as evidenced by not providing the minimum daily average of at least six tenths (0.6) hours of resident care per resident by a Registered Nurse for seven (7) of 43 sampled days.

Inspectors wroteBased on observations and interview, facility staff failed to maintain essential kitchen equipment in good working condition as evidenced by one (1) of one (1) dishwashing machine in the east-wing kitchen that squirted a water solution on both sides of the machine during the wash and rinse cycles.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain an effective pest control program as evidenced by flying insects that were observed around one (1) of one (1) handwashing sink in the east-wing kitchen.

Inspectors wroteBased on record reviews and staff interviews for five (5) of 22 sampled residents, the facility staff failed to ensure that residents had collaborative hospice care plans between the hospice agency and the facility that included a description of the care, services, and frequency of visits to be provided by the contracted hospice provider. (Residents' #13, #17, #16, #21, #27)

Inspectors wroteBased on record review and staff interviews for two (2) of three (3) sampled residents, facility staff failed to notify Medicaid residents when the amount in their account reached $200 of the SSI (supplemental security income) resource limit for both resident's accounting of funds. Residents' #6 and #7.

Inspectors wroteBased on record review and staff interview, the facility staff failed to provide adequate surety bond coverage to assure the security of all residents' personal funds deposited with the facility. The Resident census on the first day of the survey was 30.

Inspectors wroteBased on record reviews, resident representative, and staff interviews, for one (1) of 22 sampled residents, the facility staff failed to show documented evidence of notifying Resident #2's responsible party of a change in the resident's medical status on 12/01/22 and of the residents unwitnessed fall that occurred on 01/29/23.

Inspectors wroteBased on record reviews and staff interviews for one (1) of 22 sampled residents, the facility staff failed to implement its written policies and procedures for allegations of potential abuse neglect as evidenced by the facility staff failing to show documented evidence of conducting a thorough investigation into a residents fall. (Residents #135)

Inspectors wroteBased on record reviews and staff interviews for one (1) of 22 sampled residents, the facility staff failed to show documented evidence of conducting a thorough investigation into a residents fall. (Resident #135)

Inspectors wroteBased on record reviews and staff interviews for one (1) of 22 sampled residents, the facility staff failed to provide written notice of the bed hold policy to include the number of bed hold days to the resident or their responsible party upon transfer to the emergency room. (Resident #135) The findings Included: Resident #135 was admitted to the facility on [DATE], with multiple diagnoses that included Unspecified Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Repeated Falls, Syncope and Collapse. A review of a Facility Reported Incident (FRI) DC#00011029, submitted by the facility to the State Agency on 10/13/22, documented .At about 9.10 pm, resident was observed lying on the floor in her room (on her Back side) with face up. Head to toe assessment done. No injury or skin issues noted. [...]

Inspectors wroteBased on record review and staff interviews for one (1) of 22 sampled residents facility staff failed to accurately code a resident for hospice on a quarterly Minimum Data Set (MDS) assessment. Resident #21.

Inspectors wroteBased on record review and staff interviews for one (1) of 22 sampled residents facility staff failed to update and revise the care plan with resident-centered goals for one (1) resident's use of bilateral hand palm protecters. (Residents' #1).

Inspectors wroteBased on observation, record review, and staff interviews for two (2) of 22 sampled residents, facility staff failed to provide adequate supervision consistent with a resident's needs, goals, and care plan to reduce the risk of an accident, subsequently, a resident had an unwitnessed fall; facility staff failed to ensure a resident who was identified as having a high fall risk on admission received adequate supervision to prevent injury of unknown origin. Subsequently, the resident was observed with discoloration on her right eyelid and a raised area around her eyebrow; and the facility failed to provide an environment free from accident hazards as evidenced by three (3) of 51 oxygen tanks that were unsafely stored in the oxygen storage room on the [NAME] side of the facility. (Residents' #11 and #22.)

Inspectors wroteBased on record reviews and staff interviews for one (1) of 22 sampled residents, the facility staff failed to show documented evidence of reconciling Resident #27's prescribed controlled substance medication with the Pharmacy delivery staff on multiple occasions; and failed to record when controlled substance medication (Fentanyl patches) were received on the narcotic medication reconciliation log for the resident.

Inspectors wroteBased on record review and staff interview for two (2) of 22 sampled residents, facility staff failed to acknowledge and/or respond to the pharmacist medication regimen review recommendation. Residents' #6 and #25.

Inspectors wroteBased on record review, staff and resident representative interviews for one (1) of 22 sampled residents, the facility staff failed to ensure that Resident #27 was free from a significant medication error as evidenced by the resident being observed with three (3) Fentanyl patches on at once by the facility's staff and the residents relative.

Inspectors wroteBased on observations and interview, facility staff failed to store and distribute food under sanitary condition as evidenced by expired food items such as 12 of 14, V8 vegetable drinks that were in the kitchen on the East and [NAME] side of the facility.

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 22 sampled residents, facility staff failed to show documented evidence that a skin assessment was completed on admission, documented as ordered by the physician and weekly per the facility policy that accurately reflected a resident's change in skin condition. Resident #18.

Inspectors wroteBased on observations and interview, facility staff failed to provide a safe environment to residents and staff, as evidenced by three (3) of 51 oxygen tanks that were unsafely stored in the oxygen storage room on the [NAME] side of the facility.

Inspectors wroteBased on record reviews and staff interviews for six (6) of 21 sampled residents, facility staff failed to provide documented evidence that they informed and provided written information on the right to formulate an advanced directive to residents or their representatives. Residents' #16, #18, #20, #24, #25 and #131.

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that one (1) of three (3) Beneficiary Notices contained sufficient information to ensure that the resident and/or responsible party had sufficient time to appeal the facility's decision to terminate Medicare services (Resident #133).

Inspectors wroteBased on record review and staff interview for one (1) of 21 sampled residents, facility staff failed to provide written notification to the resident or resident representative of the bed hold policy and the number of bed hold days remaining following residents transfer to the hospital on [DATE].

Inspectors wroteBased on observation, record review and staff interview for one (1) of 21 sampled residents, facility staff failed to implement Resident #25's person-centered comprehensive care for contractures.

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure that the nurse's care and services for verification of shift count for narcotics drugs met the professional standard of practice.

Inspectors wroteBased on record review and staff interview for one (1) of 21 sampled residents, facility staff failed to develop and complete a discharge plan for Resident #31 that was planning to return to the community.

Inspectors wroteBased on observations, record review, and staff interview, for one (1) of 21 sampled residents, facility staff failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Resident #25.

Inspectors wroteBased on record review and staff interviews for two (2) of two (2) nursing units, the facility staff failed to ensure that the system used for an acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed.

Inspectors wroteBased on observation and staff interview, facility staff failed to store and prepare foods in accordance with professional standards of practice for food services safety as evidenced by food items such as one (1) of one (1) one-gallon plastic bag with cubed pieces of ham, one (1) of one (1) container of cooked chicken wings, one (1) of one (1) one-gallon container of slaw dressing, and one (1) of one (1) one-gallon container of sweet pickle relish, that were not labeled or dated, pieces of flounder fish that were improperly being thawed, and boxes of ice cream and muffins that were inappropriately stored in one (1) of one (1) walk-in freezer.

Inspectors wroteBased on record review and staff interview for one (1) of 21 sampled residents, facility staff failed to ensure that Resident #131's medical record did not contain inaccurate information as evidenced by staff documenting resident did not have any falls in the past 3 months on multiple falls assessment despite the resident having a documented history of falls in the medical record.

Inspectors wroteBased on observation, record review, and staff interview for one (1) of 21 sampled residents, facility staff failed to wear the required PPE (Personal Protective Equipment) when entering a resident's room and providing care for a resident that was on contact precautions due to MRSA (Methicillin-Resistant Staphylococcus Aureus).