Ingleside at Rock Creek

In the surveyor’s words

From the most serious findings on record at Ingleside at Rock Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF656Mar 26, 2025

  Based 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.) The findings included: 1. The facility staff failed to develop a care plan for Resident #8's dysphagia which was documented in the medical record. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Dementia Unspecified Severity with Agitation, Age Related Osteoporosis, Personal History of Urinary Tract Infection and Altered Mental Status. […]

• No harm, potential for more than minimal, patternF657Mar 26, 2025

  Based 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). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Osteoporosis, Arthritis, Dementia, Muscle weakness, and CVA with left side weakness. Resident #1's medical record showed the facility's staff completed the following MDS assessments: a quarterly on 08/31/24 and 12/01/24. […]

• No harm, potential for more than minimal, patternF756Mar 26, 2025

  Based 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. The findings included: An undated policy titled, Medication Regimen Review documented in part: - Policy Statement: The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. - The attending physician documents in the medical record that the irregularities has been reviewed and what (if any) action was taken to address it. […]

• No harm, potential for more than minimal, patternF849Dec 8, 2023

  Based 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) The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Atrial Fibrillation, Hypothyroidism, and Anemia. A review of a [Physician's order] dated 06/09/21 documented, admitted to [Hospice provider name] for dx [diagnoses] of Cerebral Atherosclerosis. A review of the facility care plan showed [Resident #13 name] is on [hospice provider] care. […]