Rock Creek Rehabilitation and Healthcare Center

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nursing and Physician Services Deficiencies

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.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Provide a means of sharing information on occupancy/needs.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Have exits that are accessible at all times.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper storage of liquid oxygen.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

A survey for Incident #1933087 was conducted on 10/14/25 to 12/11/25. Three deficiencies were cited.The actual survey exit date was 10/14/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider on 12/11/25. Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards received adequate supervision out of four sample residents.Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on 6/8/25, which resulted in a cervical spine fracture.During the facility’s investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1' s wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. On 6/8/25, while Resident #1 was being transported from the dining room to her room, Resident #1 caught her foot/feet on the rug, fell forward out of the wheelchair, and hit her head on the floor as she fell.Due to the facility’s failure to ensure staff used wheelchair safety equipment/foot pedals, Resident #1 sustained a fall on 6/8/25, which resulted in a cervical (C1) spine fracture. Specifically, the facility failed to ensure staff transported re.. Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for acute changes in condition out of four sample residents.Specifically, the facility failed to timely notify the physician and intervene to treat high blood pressure for Resident #1.Findings include:I. Professional reference The article Hypertensive crisis: What are the symptoms? (2024) was retrieved on 11/24/25 from https://www.mayoclinic.org/diseases-conditions/high-blood- pressure/expert-answers/hypertensive-crisis/faq-20058491?cjdata=MXxOfDB8WXww& cjevent=765460d1cfad11f082c907180a1cb829&cm_mmc=CJ-_-100357191-_-5250933-_- Evergreen+Link+for+Mayo+Clinic+Diet&utm_source=cj&utm_content=100357191&utm_capaign=3- months read in pertinent part;“A hypertensive crisis is a sudden, severe increase in blood pressure. The blood pressu.. Based on record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for maintaining resident health records out of four sample residents.Specifically, the facility failed to ensure physicians' progress notes for Resident #1 were available in the electronic medical record (EMR).Findings include:I. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 9/4/21 and discharged to the hospital on 6/8/25. According to the June 2025 computerized physician orders (CPO), diagnoses included high blood pressure, diabetes mellitus and Alzheimer’s disease.The 5/8/25 minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily livi..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. No semi annual fire alarm report available for reviewNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, .. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1.No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Re.. Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code Sections 7.8.1.1.and 7.9.2.3. 1. Missing multiple monthly inspection reports (Jul, Aug, Sep)NFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting.This deficiency has the potent.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. No previous Semi-Annual Cleaning or Inspection reports available for review NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts sha.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1.Storage door does not latch into frameNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exi.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101.1.No 5 year internal report available for inspectionNFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with th.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61.Fire Drills | No drills recorded for 1st shift, 4th quarter | 2nd and 3rd shift, 3rd quarter | 1st shift, 2nd quarter NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action r.. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility' s general characteristics.The facility is a one story Type V (000) structure with a complete National Fire Protection Association (NFPA) 13 automatic fire suppression system. The building is slab-on-grade construction without a basement. The survey was condu..

A recertification survey with complaint #CO33766 was completed from 2/5/24 to 2/8/24. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 2/5/24 to 2/8/24. No deficiencies were cited. Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one (#13) out of 17 sample residents. Specifically, the facility failed to ensure the discharge planning process focused on Resident #13' s discharge goals. Findings include: I. Resident #13A. Resident statusRe.. Based on observations and interviews the facility failed to post a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies and advocacy groups. Specifically, the facility failed to post a list of names, addresses, and telephone numbers of all pertinent state agencies, such as the State Survey Agency and.. Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for six of 22 resident rooms in two hallways.Specifically, the facility failed to ensure blinds were intact in six resident rooms.Findings include:I. Environmental tour and interviewThe environmental tour was completed with t.. Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication rooms.Specifically, the facility failed to date a multi use vial of tuberculin when opened.Findings include:I. Professional referenceAccording .. Based on observations, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interv.. Based on observations, record review and interviews, the facility failed to ensure residents received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#23) of two residents reviewed for mobility out of 17.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provide.. Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week.Specifically, the facility failed to have a RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24.Findings include:I. Record reviewReview of the nursi.. Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility' s response to grievances concerning staff, laundry and housekeeping. Findings include:I. Facility policy and pr.. Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#13, #3, #16 and #20) of five residents reviewed for vaccinations of 17 sample residents. Specifically, the facility failed to ensure Residents #13, #3, #16 and #20 were offered and..

A survey prompted by complaint #CO35066 was completed 2/5/28 to 2/8/24. One deficiency was cited. Based on observations, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interventions were implemented after each fall and implement effective interventions when they were added. The resident, who required maximum assistance with toileting according to her care plan, often fell trying to go to the bathroom. Due to the facility' s failures to implement effective interventions, Resident #16 had a major injury on 1/9/24 when she fell trying to go to the bathroom which required hospital treatment for a head laceration where she had two staples. Observations during the survey from 2/5/24 to 2/8/24 revealed the facility had not consistently implemented fall interventions.In addition, the facility failed to ensure fall interventions were utilized consistently for Resident #4.Findings include:I. Resident #16A. Resident statusResident #16, age 89, was admitted on 7/15/22. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and diabetes. The 10/2/23 facility assessment revealed the resident had a severe cognitive impairment and was unable to complete a brief interview for mental status (BIMS). The resident had behaviors of delusions and wandering. She used a wheelchair for mobility and required maximum staff assistance with transfers and ambulation. It indicated the resident had two or more falls since the prior assessment. B. ObservationsOn 2/5/24 at 10:46 a.m. Resident #16 was observed in her bed. The bed was not in the lowest position and the resident did not have a fall mat next to her bed. No positioning device was observed in the resident' s wheelchair (indicated as an intervention, see below). On 2/6/24 at 1:15 p.m. Resident #16 was observed propelling herself down the hallway tow..