Inspection visit
Inspection
Citations
43 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- 0004GeneralS&S Cno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Cno actual harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Cno actual harm
Include a process for Emergency Preparedness collaboration.
- 0013GeneralS&S Cno actual harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Cno actual harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Cno actual harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Cno actual harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Cno actual harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Cno actual harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Cno actual harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Cno actual harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Cno actual harm
Develop a communication plan.
- 0030GeneralS&S Cno actual harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Cno actual harm
Provide emergency officials' contact information.
- 0033GeneralS&S Cno actual harm
Establish methods for sharing information.
- 0034GeneralS&S Cno actual harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Cno actual harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Cno actual harm
Establish emergency prep training and testing.
- 0037GeneralS&S Cno actual harm
Establish staff and initial training requirements.
- 0039GeneralS&S Cno actual harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Cno actual harm
Implement emergency and standby power systems.
- 0100GeneralS&S Epotential for harm
Meet other general requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F687 - Foot care
Provide appropriate foot care.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 16, 2019 survey of Deep Creek Health & Rehabilitation?
This was a inspection survey of Deep Creek Health & Rehabilitation on April 16, 2019. The surveyor cited 43 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Deep Creek Health & Rehabilitation on April 16, 2019?
Yes, 43 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.