Deep Creek Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Deep Creek Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Sep 19, 2025

  Based 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. Findings included:A facility policy titled, Legionella Water Management Program, revised 07/2017, revealed Our facility is committed to the prevention, detection, and control of water-borne contaminates, including Legionella. The policy also revealed a section titled, Policy Interpretation and Implementation that specified, 1. […]

• No harm, potential for more than minimal, widespreadF925Sep 19, 2025

  Based 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. Findings included:A facility policy titled, “Pest Control,” revised 05/2008, revealed a section titled, “Policy Interpretation and Implementation” that specified, “This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.” The policy also indicated, “6. […]

• No harm, potential for more than minimal, patternF689Sep 19, 2025

  Based 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. Findings included:A facility policy titled Smoking Policy-Residents, revised 01/2020, indicated This facility shall establish and maintain safe resident smoking practices. […]

• No harm, potential for more than minimal, patternF756Sep 19, 2025

  Based 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. Findings included:A facility policy titled Medication Regimen Reviews, revised 05/2019 revealed a section titled Interpretation and Implementation that specified, 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the Attending Physician for each resident identified as having a non-life-threatening medication irregularity. […]

• No harm, potential for more than minimal, patternF835Sep 19, 2025

  Based 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. […]