Rock Creek Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff's actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information on 06/25/2026. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census. Findings Included: During an interview and record review on 06/25/2026 at 9:20 a.m., the facility's daily nurse staffing posting for current shift had not been completed. [...]

Inspectors wroteBased on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to complete facility assessment dated [DATE] leaving nurse staff section blank. This failure could place residents at risk of inadequate care or treatment and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication errors. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 5 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received his scheduled showers in February 2026. These failures could place residents at risk of not receiving services/care, decreased hygiene and decreased quality of life. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) and 1 of 7 residents (Resident #2) observed for infection control. The facility failed to ensure the Treatment Nurse wore a gown when providing wound care to Resident #2. This failure could place residents and staff at risk for MDROs, cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. During an observation on 3/3/26 at 1:32 p.m. the Treatment Nurse performed wound care on Resident #2. EBP signage and PPE observed outside Resident #2's room with a sign in red that indicated personal care gown and gloves. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure CNA B and CNA C performed hand hygiene while providing incontinent care for Resident #1 on 11/24/25. [...]

Inspectors wroteBased on observations, interviews and recorded reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure foods stored in the 1 of 1 refrigerator were removed by the use by date. The failure could place residents at risk for food-borne illnesses and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure CNA A properly transferred Resident #1 via mechanical lift (a device designed to help caregivers transfer patients) on 12/11/224 resulting in Resident #1 having a significant laceration to her scalp with exposure to underlying skull. The noncompliance was identified as PNC. The IJ began on 12/11/24 and ended on 12/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death.

Inspectors wroteBased on observations, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #1 and Resident #2) reviewed for enhanced barrier precautions and infection control practices with foley catheter care. 1. The facility failed to ensure CNA B and the DON wore enhanced barrier precautions while performing foley catheter care for Resident #1 on 10/23/2024. 2. The facility failed to ensure RN A and CNA C wore enhanced barrier precautions and performed hand hygiene while performing foley catheter care for Resident #2 on 10/23/2024. These failures could place residents and staff at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 7 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 had a baseline care plan completed within 48 hours of her admission on [DATE] that included the minimum healthcare information necessary to properly care for her including initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. The facility failed to ensure Resident #2 had a baseline care plan completed within 48 hours of her admission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 3 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was administered her fentanyl (medication used to treat severe pain) transdermal patch (patch that attaches to the skin and contains medication) every 72 hours as ordered. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 5 errors out of 26 opportunities, resulting in a 19.23 percent medication error rate for 2 of 5 residents reviewed for medication error. (Resident's #72 and #73) The facility did not ensure the following: 1. Resident #72 was given Centrum Silver (Multiple Vitamins-Minerals) as ordered by the physician on 06/18/2024. 2. Resident #72's losartan potassium (blood pressure medication) was not held for a diastolic blood pressure of 63, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. 3. Resident #73's levetiracetam (anticonvulsant medication) and baclofen (muscle relaxer) were given late on 06/18/2024. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents reviewed for medication administration. (Resident's #72 and #73) 1. Resident #72's losartan potassium (blood pressure medication) was not held for a diastolic blood pressure of 63, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. 2. Resident #73's levetiracetam (anticonvulsant medication) was given late on 06/18/2024. 3. Resident #73's nifedipine (blood pressure medication) was not held for a diastolic blood pressure of 84, according to the ordered parameters of hold for diastolic blood pressure less than 90 on 06/18/2024. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for 3 of 37 residents (Resident #54, # 41 and #76) reviewed for food form in that: 1. The facility did not ensure Resident #54 had diet orders or received meals that addressed her potential for malnutition. 2. The facility did not ensure Resident #41 was given double protein portion as ordered by the physician. 3. The facility did not ensure Resident #76 chicken parmesan was chopped as ordered by the physician. This failure could place residents at risk of not receiving food to meet their needs. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility did not ensure: 1. Sanitization buckets were at the appropriate sanitization level on 06/17/2024. 2. DA V failed to wear a hair net while in the kitchen on 06/18/2024. These failures could place residents at risk of cross-contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #68) reviewed for enhanced barrier precautions, 2 of 2 residents (Resident's #21 and #23) reviewed for respiratory care, 1 of 2 residents (Resident #69) reviewed for wound care, and 1 of 2 residents (Resident #2) reviewed for infection control practices with ADLs . 1. The facility did not ensure LVN F wore enhanced barrier precautions while administering IV medications through Resident #68's PICC line. 2. The facility did not ensure CNA C and CNA D did not contaminate clean linens with soiled linens while providing assistance with ADLs for Resident #2. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #50) reviewed for resident rights. The facility did not ensure CNA S treated residents with dignity and respect when feeding two residents at the same time during the lunch meal. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #2) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #2's call light was answered timely and within reach when leaving her room on 06/17/2024. This failure could place residents at risk for unmet needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #183) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #183 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on interview and record review, the facility failed to promptly resolve grievances for 1 out of 24 residents (Resident #41) reviewed for grievances. The facility did not ensure a grievance was filled out and followed up on after Resident #41 reported her watch was missing on 06/06/2024. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #48) reviewed for discharge MDS assessments. The facility did not ensure Resident #48's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 3 residents reviewed for care plans. (Resident #57) The facility did not ensure Resident #57's ADL care plan accurately reflected her current ADL status with transfers. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited mobility received appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 resident reviewed for mobility. (Resident #50) The facility did not provide interventions to prevent deterioration of Resident #50's range of motion in her right arm. This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident remained as free of accident hazards as possible for 1 of 2 residents (Resident # 50) reviewed for accidents and hazards. The facility failed to ensure Resident #50 had a safe transfer when the CNA allowed Hoyer lift cradle to hit her above the right eye on 06/18/2024. These failures could place residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #69) reviewed for incontinence. The facility failed to ensure Resident #69 was provided proper incontinent care and catheter care. These failures could place residents at risk for urinary tract infections and a decreased quality of life. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #68) resident reviewed for intravenous fluids. The facility did not ensure LVN F followed the policy and procedure for Resident #68's PICC line (a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) when the patency was not assessed, and resistance was met during the 10 mL saline flush. This failure could place residents at risk for PICC line associated complications such as occlusion (blockage), thrombosis (blood clot), and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and were stored in a locked compartment and only accessible by authorized personnel for 2 of 24 residents (Residents #3 and #13) reviewed for medication storage. 1. The facility did not ensure Resident #3's hydrocortisone cream (topical treatment for skin conditions) 1% was properly safe and secured. 2. The facility did not ensure Resident #13's eye drops were properly safe and secured. This failure could place residents at risk for misuse of medication and overdose, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 24 residents (Residents #3 and #22) reviewed for laboratory services. The facility did not obtain a physician's ordered CBC (used to measure different parts and features of blood), CMP (test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipids (levels of cholesterol and other fats in the blood), TSH (test used to measure hormone), T4 (test used to measure thyroxine in the blood) for Resident #3. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure [NAME] F followed the recipe for pureeing the hamburger beef patties for the lunch meal on 06/18/2024. This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 17 residents (Resident #53, Resident #5 and Resident #282) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Resident #53, Resident #5, and Resident #282. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: food items were dated, labeled, and sealed appropriately. expired food items were discarded. Temperature checks were completed on the salad bar These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interviews and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Data Set (MDS) specified by the state and approved by CMS for 1 of 4 resident (Resident #18) reviewed for quarterly assessments. The facility failed to ensure Resident #18's MDS assessment was completed within three months of her last assessment. This failure could place residents at risk for not having their assessments completed timely and not having their individually assessed needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete annual comprehensive MDS assessment was transmitted to the CMS System within 14 days after completion for 2 of 5 residents (Residents #24 and #49) reviewed for MDS assessments transmissions. The facility did not ensure Resident #24's and Resident #49's discharge MDS assessments were transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 21 residents reviewed for MDS accuracy. (Resident #40) The facility failed to accurately document Resident #40's bladder status of having an indwelling urinary/foley catheter (tube inserted into the resident's bladder to drain urine) on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 5 residents (Resident # 36) reviewed for MDS completion. The facility failed to ensure the RN signed Resident #36's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 21 residents reviewed for care plans. (Resident #40). The facility failed to develop and implement a care plan for Resident #40 having a urinary/foley catheter (tube inserted into the resident's bladder to drain urine). This failure could place residents at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 of 5 residents (Resident #7) reviewed for respiratory care and services. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #7. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #56) The facility failed to keep ongoing communication with the dialysis facility and did not ensure the post-dialysis assessments were completed for Resident #56. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.