Rock Creek Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure two (#25 and #35) of eight out of 24 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #25 from verbal abuse from Resident #3 on 12/15/25 and 12/21/25, which caused psychosocial distress for Resident #25; and,-Protect Resident #35 from verbal abuse from Resident #3 on 12/23/25 and 12/31/25, which caused Resident #35 to become tearful after both incidents. Resident #3, who was admitted to the facility on [DATE] and readmitted on [DATE], was known to have verbally aggressive behaviors toward others and had been involved in verbal altercations with other residents. On 12/15/25 Resident #3 verbally abused Resident #25 in the dining room by yelling foul language, making threatening comments and moving aggressively toward Resident #25. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Maintain the ice machine in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated and discarded within appropriate use-by timeframes.

Inspectors wroteBased on record review and interviews, the facility failed to take appropriate corrective actions, as a result of abuse investigations, for four of nine abuse allegations. Specifically, the facility failed to take appropriate corrective action following the investigations of four verbal abuse incidents by Resident #3 towards Resident #25 on 12/15/25 and 12/21/25, and Resident #35 on 12/23/25 and 12/31/25, to ensure that verbal abuse did not recur.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#7) of five residents out of 24 sample residents. Specifically, the facility failed to ensure Resident #7, who was receiving an antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements that can be caused by taking antipsychotic medications) did not worsen.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient discharge preparation for one (#22) of one resident reviewed for a safe and orderly discharge out of 24 sample residents. Specifically, the facility failed to ensure a written bed hold notice was provided to Resident #22 and/or her representative at the time of the resident's transfer to the hospital.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for one (#10) of two residents out of 24 sample residents. Specifically, the facility failed to maintain, clean, sanitize and properly store Resident #10's nebulizer machine (breathing treatment device) and mask.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of one resident reviewed for pain out of 24 sample residents. Specifically, the facility failed to:-Ensure a thorough pain assessment was completed that identified Resident #37's history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident's quality of life; -Identify Resident #37's goals for pain management and the resident's acceptable level of pain; -Ensure Resident #37's location of pain was consistently identified when administering pain medication to the resident; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well being for one (#3) of seven residents out of 24 sample residents. Specifically, the facility failed to identify Resident #3's history of depression to monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs of the resident.

Inspectors wroteBased 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 [DATE], 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 [DATE], 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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/or received pneumococcal immunization.

Inspectors wroteBased 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.

Inspectors wroteBased 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 sample residents. Specifically, the facility failed to ensure a carrot contracture prevention device was placed according to physician orders for Resident #23.

Inspectors wroteBased 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 provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #3, CNA #4 and CNA #5.

Inspectors wroteBased 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.

Inspectors wroteBased 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 the Office of the State Long-Term Care Ombudsman program.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNAs) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to complete staff competencies for all CNAs.

Inspectors wroteBased on record review and interviews, the facility failed to establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program for one (#1) of five residents reviewed of 18 sample residents. Specifically, the facility: -Failed to track antibiotic usage in the facility, and -Failed to assess for the appropriate use of an antibiotic for Resident #1.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store and prepare food under sanitary conditions. Specifically, the facility failed to ensure: -Cutting boards were free from deep scratches and stains; and -Food was stored properly, off the floor.

Inspectors wroteBased on record review and staff interview, the facility failed to inform one (#135) of three residents reviewed for liability notices and beneficiary appeal rights of 18 sample residents, both orally and in writing in a language that the resident understood, of their rights. Specifically, the facility failed to provide Resident #135 or their representative a notice of discharge from Medicare services, ensuring acknowledgement of their rights to appeal the discharge.

Inspectors wroteBased on record review and interviews, the facility failed to refer one (#4) of one resident reviewed of 18 sample residents to the appropriate state-designated authority for level II preadmission screening and resident review (PASARR) evaluation and determination for services. Specifically, the facility failed to update a PASARR level II for the use of lamotrigine (a mood stabilizer) and for a patient health questionnaire (PHQ-9) score of 12 out of 27.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, their comprehensive, person-centered care plan and the resident's choice for one (#133) of one resident reviewed for quality of care of 18 sample residents. Specifically, the facility failed to ensure donning of Geri sleeves per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with the comprehensive person-centered care plan and the residents' goals and preferences for two (#26 and #4) of three residents reviewed for oxygen therapy out of 18 sample residents. Specifically, the facility: -Failed to ensure oxygen was delivered at the ordered liter flow for Resident #26; and -Failed to ensure Resident #4 had a physician's order for the use of oxygen.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to monitor and document behaviors to prevent behavioral difficulties for three (#4, #132, and #24) of five residents reviewed for behaviors of 18 sample residents. Specifically, the facility failed to: -Monitor and document behaviors and outbursts for Resident #4; -Monitor and document wandering/elopement behaviors for Resident #132; and -The facility failed to effectively track and care plan individualized interventions for Resident #24 who had a diagnosis of dementia.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide person-centered dementia care services to two (#26 and #21) of five residents reviewed of 18 sample residents. Specifically, the facility failed to develop and implement person-centered interventions so Residents #26 and #21 could reach their highest practicable quality of life.