Rock Creek Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer and discharge was appropriate for one of three sampled residents (Resident 1), when the resident was not provided with the required discharge notices when transferred to the hospital and was not permitted to return to the facility. This failure resulted in Resident 1's unnecessary admission in the hospital with no information on resident rights or how to file an appeal to remain in the skilled nursing facility (SNF), and had the potential risk of not attaining Resident 1's highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store cookware pans and utensils in accordance with professional standards for food service safety when:2 steam table pans were found wet while stored away2 spatulas, 1 whisk were found wet while stored in the dry storage area1 steam table lid was found with dried food debris at the dry storage area1 gray scoop, and 1green serving spoon found with dry food debris in the dry storage area. These failures had potential to cause food-borne illnesses in a highly susceptible population of 80 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure activities of daily living (ADLs) were provided to one of 19 sampled residents when Resident 82 was not provided with a shower for a week. This failure had the potential to further negatively impact Resident 82's psychosocial well-being and carried a risk for skin breakdown, leading to infection. A review of Resident 82's admission Record indicated Resident 82 is a [AGE] year old female who was admitted in January of 2026 with multiple diagnoses including radiculopathy (a pinch nerve in the spine causing symptoms like pain, numbness, tingling, or weakness that can radiate from the back into the arms or legs), difficulty walking and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide 80 square feet of space per resident in rooms 1-8, 11, 12, 17, 18, 19, 21, and 23-36. This failure decreased the facility's potential to provide adequate personal space for the residents in these rooms for a census of 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store food for a census of 84 residents, when unlabeled and expired food items were stored in the facility ' s kitchen. This failure had the potential to lead to foodborne illness among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was being following for the therapeutic diet for lunch on 10/9/24 when: 1. Three residents (Resident 30, 49, and 64) were on modified texture diets, Dysphagia Mechanical (diet is for people with mild to moderate chewing and/or swallowing difficulty) and Pureed (diet is for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) who received no wheat roll for bread instead of receiving pureed roll (for Pureed diet) or chopped and milk-soaked wheat roll (for Dysphagia Mechanical diet) as indicated on the menu; 2. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various metal sheet pans in clean and ready-to-use storage areas: a. Were stacked wet while stored away b. Had food debris; 2. There were opened bags of food items in dry storage and freezer with issues: a. One opened bag of elbow noodles was not tightly closed b. One opened bag of croutons was not labeled with an open or use by date c. One opened package of hamburger meat patties was not labeled with an open or use by date; 3. The thawing process system did not effectively identify when food was pulled from the freezer and used by date; 4. The ice machine was not clean; 5. The hot food cool down was not practiced correctly; 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: 1. Dietary Aides (DA) 1 and DA 2, were unable verbalized the process of manual dishwashing by using three-compartment sinks correctly (cross refer to F812, #6), and 2. DA 2 was unable to verbalize the concentration of sanitizer solution for the sanitation (red) bucket (a red color-coded bucket with sanitizer solution for food service staff to sanitize food contact surfaces) (cross refer to F812, #7). These failures had the potential to place 75 out of 75 highly susceptible residents who received food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for two of 25 sampled residents (Resident 17 and Resident 25), when the call light was not within reach. This failure had the potential to result in the residents not attaining their highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate assessment was performed for one resident (Resident 22) of 25 sampled residents when Resident 22's dental/oral assessment was inaccurate. This failure resulted in Resident 22 not receiving care reflective of the residents' status and needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for one of 25 sampled residents (Resident 378) when one Certified Nursing Assistant (CNA) transferred Resident 378 by herself using a Hoyer lift (an electronically operated mechanical lift used to transfer a patient from place to place). This failure had the potential for Resident 378 to receive unsafe care.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection prevention and control practices for one of 25 sampled residents (Resident 379) when the Certified Nursing Assistant (CNA 2) did not wear the proper Personal Protective Equipment (PPE-gown, eye protection or face shield and gloves) upon entering Resident 379's room with an isolation precaution sign. This failure put the residents at increased risk for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 28 multiple-resident rooms (rooms 1-8, 11, 12, 17-19, 21, 23-36) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as: room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 71.45 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 75.5 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 74.5 sq. ft. per person room [ROOM NUMBER] at 74.5 sq. ft. per person room [ROOM NUMBER] at 76.9 sq. ft. per person room [ROOM NUMBER] at 74.67 sq. ft. per person room [ROOM NUMBER] at 72.1 sq. ft. per person room [ROOM NUMBER] at 74.67 sq. ft. per person room [ROOM NUMBER] at 73.83 sq. ft. per person room [ROOM NUMBER] at 78.93 sq. ft. per person room [ROOM NUMBER] at 70.47 sq. ft. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that was palatable when three of seven sampled residents (Resident 3, Resident 4, and Resident 7) had food that was served cold. This failure had the potential for Resident 3, Resident 4, and Resident 7 to experience dissatisfaction with meals leading to decreased intake with possible weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for one of six sampled residents (Resident 3), when Resident 3's call light was not within reach. The failure had the potential to result in the resident not attaining her highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to ensure professional standards of quality were maintained for one of six sampled residents (Resident 1), when Resident 1's surgical staples were not removed on the date ordered by the physician. This failure had the potential to cause an infection in Resident 1's wound.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were maintained for one of six sampled residents (Resident 2), when Resident 2 did not receive chlordiazepoxide (a medication used to treat alcohol withdrawal symptoms) according to physician orders. This failure resulted in Resident 2 to have experienced uncomfortable symptoms and had the potential to cause Resident 2 to relapse during alcohol detoxification.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when ready to use dishware was found dirty and in uncleanable condition. These failures had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) to all residents.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate treatment and services were provided to two of four sampled residents (Resident 1 and Resident 2) when the Restorative Nursing Assistant program (RNA program: provides residents with exercises to improve or maintain mobility and strength) services were not implemented per the physician's order. This deficient practice had the potential to result in Resident 1 and Resident 2 experiencing declines in range of motion and strength.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication storage policy and procedures were followed, in a census of 75, when medications requiring storage in the refrigerator were kept at temperatures lower than the recommended range. This failure had the potential risk to decrease the effectiveness of the medications stored in the refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the cooks utilized standardized recipes for food preparation to ensure the nutritive value and palatability of the meals served. This failure had the potential to negatively impact the resident's nutritional status and not meet the residents' preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and prevent hazards at specific points of food handling in a census of 75, when: 1. Kitchen staff did not wash their hands before handling food; and 2. Food trays were found wet and were used to serve food. These failures had the potential to put vulnerable residents receiving food from the kitchen, at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet of space per resident in rooms 1-8, 11, 12, 17-19, 21, and 23-36 for a census of 75. This failure increased the potential for inadequate personal space and the residents' ability to move freely in their rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free from pests for a census of 75, when rodent droppings were found, and scattered garbage and debris were found behind and between two garbage bins. This failure resulted in the presence of pests inside the facility and had the potential to result in the transmission of infection caused by rodents and pests.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident needs and personal requests were accommodated for three of 24 sampled residents (Resident 27, Resident 14 and Resident 17), when: 1. An appropriate call light was not provided to Resident 27; 2. Wheelchair footrests were not provided to Resident 14; and 3. An appropriate adaptive equipment was not provided to Resident 17 according to physician's orders. These failures had the potential to result in the residents not attaining their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policy and procedures were followed in accordance with professional standards of practice when licensed nurses did not verify a pain medication's dosage strength on an order for Resident 9, in a census of 75. This failure had the potential to affect Resident 9's health, pain and comfort level.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pharmaceutical services policies and processes related to reconciliation of narcotic medications (drugs that have potential for abuse or dependence) for Resident 20, in a census of 75.

Inspectors wroteBased on observation, interview, and record review, one of 24 sampled residents (Resident 24) failed to receive the correct dose of a psychotropic medication (drug prescribed to affect the mind, emotions, or behavior), when Resident 24's new physician's order for aripiprazole (antipsychotic, a type of psychotropic medication to treat mental health conditions such as depression) Gradual Dose Reduction (GDR) was not initiated as per physician's order. This failure had the potential for Resident 24 not attaining the desirable effect of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility had a 6.9 % error rate, when two medication errors out of 29 opportunities were observed during a medication pass for two residents (Residents 1 and Resident 9). This failure resulted in medications not being given in accordance with the prescriber's orders, which resulted in residents not receiving the intended therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 17) was provided with necessary adaptive equipment for meals, as ordered by the physician. This failure had the potential to negatively impact the resident's well-being and contribute to lower meal intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the outside garbage dumpster area was clean and litter free for a census of 75. This failure had the potential to attract rodents that carry diseases and create an unsanitary environment for facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the walk-in freezer in safe operating condition in a census of 75, when the walk-in freezer had ice buildup and a damaged gasket (a rubber seal that keeps the door tight to maintain the temperature). This failure had the potential to cause the freezer to not operate efficiently, which would result in thawing and possible contamination of food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for one of 24 sampled residents (Resident 9), when a mouse trap with mouse droppings were found in the resident's room. This failure resulted in Resident 9's decreased sense of emotional well-being and had the potential for the transmission of diseases.