Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock Creek Of Ottawa during CMS and state inspections, most recent first.
A resident with morbid obesity, COPD, osteoporosis, bilateral impairment, and cognitive impairment, who was dependent on staff and required a mechanical lift for transfers, was being moved by two CNAs from a wheelchair to a recliner using a Hoyer lift. As the resident was lowered, the top left sling strap came off the lift hook, and the resident slid to the floor, later being diagnosed with a left humerus fracture and returning with a shoulder immobilizer. An administrative nurse found the lift and sling functioning normally and determined during observation of the involved CNAs that they failed to maintain proper tension on the sling straps before raising the lift, allowing the sling to shift and the loops to detach, leading to the fall and injury.
The facility failed to ensure proper food storage and temperature management, leading to a deficiency in food safety standards. Observations revealed improperly sealed, labeled, or dated food items, and the walk-in freezer was not maintaining the required temperature. The previous dietary manager failed to log food temperatures and did not inform staff about the freezer's malfunction, resulting in resident complaints of nausea, vomiting, or diarrhea.
The facility failed to properly store and label medications, as two medication carts were found unlocked and unattended, with one containing opened and undated insulin pens. A CMA admitted to leaving the cart unlocked, and a LN confirmed that carts should not be left unlocked when out of view. The facility's policy required medications to be stored securely and labeled correctly, which was not followed, placing residents at risk.
A facility failed to ensure the privacy and dignity of a resident with chronic respiratory failure and dementia. The resident was observed in bed with the room door open, exposing his right leg and brief. Staff interviews confirmed that privacy measures should have been in place, but the facility did not provide a policy on dignity when requested.
The facility failed to use foot pedals during wheelchair transports for two severely cognitively impaired residents, resulting in one resident falling and sustaining minor injuries. Additionally, call lights were not within reach for three cognitively impaired residents, placing them at risk for preventable accidents and injuries.
A facility failed to provide written notification of transfer to a resident and their representative for several facility-initiated transfers to an acute hospital. The resident, with chronic respiratory failure, dementia, and CHF, required substantial assistance and supplemental oxygen. Despite these needs, the facility did not provide necessary written notifications for transfers, placing the resident at risk for uninformed care choices. Staff were unaware of the requirement for written notifications, and the facility's policy lacked guidance on this federal requirement.
A facility failed to set a resident's low air-loss mattress to the correct weight and did not ensure a pressure-reducing cushion was in another resident's wheelchair. Both residents were at risk for pressure ulcers, with one having a history of such injuries. Observations and staff interviews confirmed these deficiencies, which were contrary to the facility's Skin Management System policy.
A facility failed to provide necessary services to prevent worsening contractures in a resident's left hand. The resident had a history of contracture, hemiparesis, hemiplegia, and cerebral infarction, with severely impaired cognition and limited ROM. Despite a care plan for supportive devices, there was no documentation of their use, and observations showed the resident without these devices. Staff interviews revealed unclear documentation procedures, and the facility's ROM policy was not followed, risking further decline and discomfort for the resident.
The facility failed to secure an electrical furnace closet, making it accessible to 30 cognitively impaired residents, and did not ensure a resident's fall interventions were in place. The closet doors were easily opened, exposing high voltage electrical boxes, and a resident at high fall risk was observed without the necessary Dycem in her wheelchair, contrary to the care plan.
A resident with an indwelling catheter was found with their catheter drainage bag resting on the floor, contrary to the facility's policy. The resident had diagnoses of benign prostatic hyperplasia, cognitive-communication deficit, and hypertension, and was dependent on staff for toileting. Staff interviews confirmed the catheter bag should not be on the floor, but challenges were noted in attaching the bag to recliners.
A resident with chronic respiratory failure and other conditions did not receive continuous oxygen therapy as ordered by the physician. Observations showed the nasal cannula was not in use, and the oxygen concentrator was off, contrary to the care plan and physician's orders. Staff interviews confirmed the oversight, highlighting a failure to adhere to the facility's oxygen administration policy.
A resident with severe cognitive impairment did not receive prescribed eyedrops for over a week due to nursing staff's failure to verify and enter the medication order into the EMR system. Despite receiving the medication and instructions, the facility did not follow up with the resident's medical provider promptly, delaying the administration of the medication and placing the resident at risk for impaired quality of care.
A resident with Alzheimer's disease and severe cognitive impairment experienced multiple non-injury falls due to inadequate dementia-related behavioral services. The facility's care plan and interventions, such as the use of a soft-touch call light and fidget devices, were insufficient and poorly documented. The resident's impulsiveness and lack of safety awareness, combined with missing safety equipment, contributed to the falls, highlighting a failure to adhere to the facility's dementia care policy.
A facility failed to follow physician parameters for a hypertensive medication prescribed to a resident with congestive heart failure and hypertension. The resident's MAR showed blood pressure readings below the set parameters, but these were not documented in the clinical record. Staff interviews revealed that the CMA was aware of the need to hold the medication if blood pressure was outside parameters but failed to document it. This resulted in the potential for unnecessary medication administration.
A facility failed to ensure a resident had a CMS-approved indication for the antipsychotic medication Seroquel, used for managing moods related to Alzheimer's dementia with agitation. The resident's care plan included documentation of agitation and non-pharmacological interventions, but there was no pharmacy review for the medication. Staff interviews revealed uncertainty about the appropriate diagnosis for Seroquel use, and the facility did not provide a policy on psychotropic medications when requested.
The facility failed to follow infection control practices for oxygen equipment and Foley catheter care, risking resident safety. A resident's catheter bag was on the floor, and another's oxygen cannula was not stored properly. Staff interviews confirmed these practices violated the facility's infection prevention policy.
Improper Hoyer Lift Technique Leads to Resident Fall and Fractured Humerus
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide safe mechanical lift transfers for a resident who required staff assistance and a Hoyer lift for all transfers. The resident had morbid obesity, COPD, osteoporosis, bilateral impairment, and moderate to severe cognitive impairment, and was dependent on staff for transfers, toileting, and bathing per MDS and CAA assessments. These assessments documented that the resident required a mechanical lift for transfers and was dependent on staff for mobility-related ADLs. On the date of the incident, two CNAs were transferring the resident using a Hoyer lift from a wheelchair to a recliner. According to the facility’s incident report and notarized witness statements from both CNAs, one CNA operated the Hoyer lift from the front while the other CNA guided and positioned the resident from behind the recliner. As the resident was being lowered into the recliner, the top left sling strap/loop came off the Hoyer hook, causing the resident to slide out of the sling and fall to the floor. The resident immediately complained of left shoulder pain and right shin pain, and staff observed a bruise on the right wrist. The resident was sent to the ER, where imaging confirmed a left humerus fracture measuring 3.1 cm, and the resident returned with a shoulder abduction immobilizer. An administrative nurse later inspected the lift and sling and found both to be functioning within normal limits. During subsequent transfer training with the involved CNAs, the administrative nurse observed that when the CNAs placed the sling strap loops onto the lift, they did not ensure there was tension on the straps before raising the lift, which allowed the lift sheet to shift to one side and the loops to come off the lift. This improper technique directly contributed to the sling strap detaching from the lift and the resident’s fall and injury.
Deficiency in Food Storage and Temperature Management
Penalty
Summary
The facility failed to ensure proper food storage and temperature management, leading to a deficiency in food safety standards. Observations revealed that several food items, including cottage cheese, milk, bread, macaroni, pasta shells, potato patties, chicken strips, and breadsticks, were not properly sealed, labeled, or dated. Additionally, the facility's walk-in freezer was not maintaining the required temperature, and there were alterations in the temperature logs for the freezer. The facility was unable to provide daily prepared food temperature logs, and there were missing food temperature readings for specific dates in December 2024. The deficiency was further compounded by the lack of communication and documentation from the previous dietary manager, who failed to log food temperatures and did not inform administrative staff about the freezer's malfunction in a timely manner. This resulted in numerous resident complaints of nausea, vomiting, or diarrhea during the first few days of December 2024. Interviews with dietary staff and administrative personnel confirmed the lack of proper food temperature logging and the abrupt departure of the previous dietary manager, which contributed to the oversight in maintaining food safety standards.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store and label medications, as observed during a survey. On the initial tour, two medication carts on the same hallway were found unlocked and unattended. One of these carts contained two opened and undated insulin pens. A Certified Medication Aide (CMA) admitted to mistakenly leaving the cart unlocked, acknowledging that it should never be left unattended and unlocked. A Licensed Nurse (LN) confirmed that medication carts should not be left unlocked when out of view and that insulin pens should be labeled with both an open date and a discard date. Further interviews revealed that the facility's policy required medications to be stored safely, securely, and properly, following the manufacturer's recommendations and federal and state laws. The Administrative Nurse stated that insulin pens should be stored in the refrigerator until use, and once removed, they should be labeled with an open date and a discard date and stored in a locked medication cart. The facility's failure to adhere to these protocols placed residents at risk for adverse outcomes or ineffective medication regimens.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident, identified as R28, while he was in bed. R28 had a medical history of chronic respiratory failure, dementia, and congestive heart failure, and required substantial assistance for activities of daily living. Observations revealed that R28 was lying in bed with his room door open, and his right leg and brief were visible from the doorway, indicating a lack of privacy. The privacy curtain in the room was not drawn, which exposed R28 to anyone passing by. Interviews with facility staff, including a Certified Nurse Aide and a Licensed Nurse, confirmed that residents should not be exposed and that privacy measures such as closing the door or drawing the curtain should be in place. Despite these acknowledgments, the facility did not provide a policy regarding dignity when requested. This oversight in maintaining R28's privacy and dignity placed him at risk of decreased self-esteem and self-worth.
Failure to Ensure Proper Use of Assistive Devices and Call Light Accessibility
Penalty
Summary
The facility failed to ensure the appropriate use of foot pedals during wheelchair transports for two residents, both of whom were severely cognitively impaired. One resident fell out of his wheelchair while being pushed in the hallway without foot pedals, resulting in a minor injury with skin tears on his left elbow, wrist, hand, and below his left eye. Another resident was observed being pushed in a wheelchair without foot pedals, requiring staff to remind him to pick up his feet. Additionally, the facility did not ensure that call lights were within reach for three residents, all of whom were cognitively impaired. One resident was unable to reach her call light, which was placed across the room, while another resident's call light was pinned to the wall at the foot of her bed, out of reach. A third resident's call light was stuck between the mattress and bed cane, making it inaccessible. These deficiencies placed the residents at risk for preventable accidents and injuries.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident, identified as R28, and his representative for several facility-initiated transfers to an acute hospital. This deficiency was identified during a survey that included a sample of 19 residents, with four reviewed for hospitalization. The lack of written notification included the absence of details such as the reason for the transfer, the effective date, the specific location, the right to appeal, and contact information for the state entity and ombudsman. This oversight placed R28 at risk for uninformed care choices. R28's medical history included chronic respiratory failure, dementia, and congestive heart failure. The resident had moderately impaired cognition, required a wheelchair for mobility, and needed substantial assistance with activities of daily living. R28 was frequently incontinent and required supplemental oxygen and a BiPAP machine. Despite these needs, the facility did not provide the necessary written notifications for transfers on multiple occasions, including specific dates in March, May, July, August, and December. Interviews with facility staff, including social services and nursing personnel, revealed a lack of awareness regarding the requirement for written notifications. Staff members indicated that they typically called the resident's representative to inform them of a transfer but did not provide written documentation. The facility's discharge or transfer policy, last revised in January 2023, did not include guidance on the federal requirement for notice before transfer, as outlined in the CMS state operations manual.
Failure to Ensure Proper Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress was set to the appropriate weight settings according to her current weight. The resident, who had a history of muscle weakness, cognitive impairment, and pressure ulcers, was admitted with two stage-two pressure injuries and was at risk for further pressure injury development. Despite the resident's weight being recorded as 135.4 lbs, the mattress was locked at a setting for 200 lbs, which was not adjusted to match her current weight. This oversight was noted during observations, and staff interviews revealed a lack of clarity on how to adjust the mattress settings to accommodate weight changes. Additionally, the facility failed to ensure that another resident's wheelchair had a pressure-reducing cushion in place as per her care-planned interventions. This resident, who had a history of pressure ulcers and was at risk for skin breakdown, was observed multiple times without the necessary pressure-reducing cushion in her wheelchair. Staff interviews confirmed that the cushion was expected to be in place to prevent further skin breakdown, yet it was consistently missing during observations. The facility's Skin Management System policy required the implementation of preventative interventions to minimize the risk of skin breakdown and pressure injuries. However, the failure to properly set the low air-loss mattress and ensure the presence of a pressure-reducing cushion in the wheelchair placed both residents at risk for complications related to skin breakdown and pressure ulcers.
Failure to Prevent Worsening of Contractures in Resident
Penalty
Summary
The facility failed to provide necessary services and treatment to prevent the worsening of contractures in a resident's left hand. The resident, identified as R24, had a medical history that included contracture of the left hand, hemiparesis, hemiplegia, and cerebral infarction. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and limited range of motion (ROM) in the upper and lower extremities on one side, requiring staff assistance for activities of daily living. Despite a care plan that included the use of supportive devices such as a washcloth, a weighted stuffed animal, and a hand splint to prevent further contracture formation, there was no documentation of these devices being applied or refused from December 1, 2024, to January 29, 2025. Observations on multiple occasions revealed that the resident was not using any contracture prevention devices, and the call light was out of reach, indicating a lack of adherence to the care plan. Interviews with staff, including a Certified Medication Aide and a Licensed Nurse, revealed a lack of clarity on documentation procedures for the application of supportive devices. The facility's policy on range of motion, revised in January 2023, emphasized the importance of preventing loss of ROM and providing appropriate treatment to increase or maintain ROM. However, the facility did not ensure that the resident received the necessary services and treatment, leaving the resident at risk for further decline and discomfort.
Failure to Secure Hazardous Areas and Implement Fall Interventions
Penalty
Summary
The facility failed to secure an electrical furnace closet, which was easily accessible due to damage to the door's frame, placing 30 cognitively impaired and independently mobile residents at risk for preventable injuries and accidents. During an initial walkthrough, it was observed that the closet doors, although locked, could be easily pulled open, exposing numerous electrical boxes with high voltage warnings. Administrative staff confirmed the issue and acknowledged that the room should be lockable, as per the facility's accident policy, which mandates an environment free from hazards. Additionally, the facility did not ensure that a resident's care-planned fall interventions were in place. The resident, who had a history of falls and was identified as a high fall risk, was observed without the necessary Dycem in her wheelchair, which was intended to prevent her from sliding out. Despite the care plan specifying the use of Dycem, staff members were either unaware or did not ensure its presence, contrary to the facility's fall prevention policy. This oversight placed the resident at further risk for injuries related to falls.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment for a resident, identified as R67, who had an indwelling catheter. The deficiency was observed when R67's catheter drainage bag was found resting directly on the floor under his recliner. This observation was made despite the facility's policy and care plan, which required that the catheter bag and tubing be positioned below the level of the bladder and away from the entrance of the room door. The facility's policy also mandated daily catheter care to promote hygiene and reduce infection risk. R67's medical records indicated diagnoses of benign prostatic hyperplasia, cognitive-communication deficit, and hypertension. The resident was noted to have severely impaired cognition and was dependent on staff assistance for toileting. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that the catheter bag should not be placed on the floor. An administrative nurse acknowledged the difficulty in finding a suitable place to attach the catheter bag on recliners. The failure to adhere to the facility's catheter care policy placed R67 at risk for catheter-related complications.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as R28, received physician-ordered supplemental oxygen continuously as required. Observations revealed that R28's nasal cannula was not in use and was not stored in the provided storage bag, with the oxygen concentrator turned off. This oversight was noted despite R28's medical history, which included chronic respiratory failure, dementia, and congestive heart failure, conditions that necessitate continuous oxygen support. The resident's care plan and physician's orders clearly indicated the need for continuous oxygen via nasal cannula, yet this was not adhered to. Interviews with facility staff, including a Certified Nurse Aide and a Licensed Nurse, confirmed that R28 was supposed to be on continuous oxygen and that the nasal cannula should be stored properly when not in use. The staff acknowledged their responsibility to ensure the resident's oxygen was on to prevent further respiratory issues. The facility's policy on oxygen administration also supported the need for adherence to physician orders. The failure to provide continuous oxygen and properly store the nasal cannula placed R28 at risk of respiratory complications and possible infection.
Failure to Administer Prescribed Eyedrops
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate skills and knowledge to manage a resident's physician-ordered medication. A resident with severe cognitive impairment and multiple medical conditions, including dementia and a history of stroke, was prescribed Refresh Plus Ophthalmic Solution for dry eyes. Despite receiving the medication and instructions from the resident's representative, the nursing staff did not add the eyedrops to the resident's orders or administer them as prescribed. The facility did not follow up with the resident's outside medical provider in a timely manner, resulting in a delay of over a week before the medication was reordered and administered. Interviews with facility staff revealed that the nurse on duty was responsible for verifying and entering outside orders into the Electronic Medical Records (EMR) system. However, this process was not completed, leading to a lapse in the resident's medication routine. The facility's Nursing Staff Competency policy, which mandates that staff have the necessary competencies and skills to ensure resident safety, was not adhered to in this instance. This oversight placed the resident at risk for impaired quality of care due to the failure to administer the prescribed medication.
Failure to Provide Adequate Dementia Care Leads to Multiple Falls
Penalty
Summary
The facility failed to provide adequate dementia-related behavioral services for Resident 65, who was diagnosed with Alzheimer's disease and exhibited severe cognitive impairment. The resident's medical records indicated a history of falls, dysphagia, muscle weakness, and cognitive-communication disorder. Despite these conditions, the facility did not effectively implement interventions to prevent falls and promote the resident's well-being. The care plan noted the need for substantial assistance with daily activities and the use of a soft-touch call light, but these measures were insufficient to prevent multiple non-injury falls. Observations and interviews revealed that the resident experienced several falls due to impulsiveness and lack of safety awareness. The facility's records showed that the resident fell out of his wheelchair and bed on multiple occasions, often due to missing or improperly used safety equipment such as foot pedals and fall mats. The facility attempted to engage the resident with fidget devices and conversations about farming, but these efforts were inconsistent and poorly documented. Staff interviews confirmed that the resident often refused sensory devices, and there was a lack of documentation regarding these refusals. The facility's policy on dementia care emphasized individualized care interventions and the use of the least restrictive approaches. However, the facility did not adhere to this policy, as evidenced by the resident's repeated falls and lack of engagement in meaningful activities. The failure to provide appropriate dementia-related behavioral services placed the resident at risk for decreased quality of life, isolation, and impaired dignity, as noted in the report.
Failure to Follow Physician Parameters for Hypertensive Medication
Penalty
Summary
The facility failed to ensure that physician parameters were followed for a hypertensive medication prescribed to a resident with a history of congestive heart failure and hypertension. The resident's electronic medical record indicated that Carvedilol, an antihypertensive medication, was to be held if the systolic blood pressure was less than 110 mmHg or the diastolic blood pressure was less than 60 mmHg. However, the Medication Administration Record (MAR) showed that the resident's blood pressure was below the set parameters on several occasions, yet there was a lack of documentation of the blood pressure readings in the clinical record. Interviews with facility staff revealed that the Certified Medication Aide (CMA) was aware of the need to hold the medication if the blood pressure was outside the parameters but failed to document the blood pressure readings on the MAR. The Licensed Nurse confirmed that blood pressure readings should be recorded and reported if they fall outside the physician-ordered parameters. The facility's policy required that drugs be administered only upon the written order of a licensed prescriber, and the failure to adhere to this policy resulted in the potential for unnecessary medication administration, which could lead to harmful side effects.
Inadequate CMS-Approved Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R8, had an adequate CMS-approved indication for the use of the antipsychotic medication Seroquel. R8, who had diagnoses of Alzheimer's disease, dementia, and hypertension, was taking Seroquel daily to manage moods related to Alzheimer's dementia with agitation. However, the facility did not have a CMS-approved diagnosis for the use of this antipsychotic medication. The resident's care plan included documentation of episodes of agitation and the use of non-pharmacological interventions, but there was no evidence of a pharmacy review for the medication. Interviews with facility staff revealed a lack of clarity regarding the appropriate diagnosis for the use of Seroquel. A licensed nurse stated that the pharmacy typically assists with medication reviews, but there was no indication that a review had been conducted for R8. The administrative nurse acknowledged that Alzheimer's disease and dementia are not approved diagnoses for antipsychotic use and mentioned the need to obtain appropriate documentation from the resident's physician. The facility also failed to provide a policy regarding psychotropic medications or physician orders when requested, highlighting a deficiency in ensuring proper medication administration and documentation for R8.
Infection Control Deficiencies in Oxygen and Catheter Equipment Handling
Penalty
Summary
The facility failed to adhere to sanitary infection control practices concerning the storage of oxygen equipment and the care of Foley catheters, which placed residents at risk for infectious diseases. During an observation, a resident's urinary catheter collection bag was found resting directly on the floor, with amber-colored urine visible inside. This practice contradicts the facility's policy, which requires that the collection bag be maintained below the level of the bladder and not touch the floor to prevent contamination and potential infection. Additionally, another resident's supplemental oxygen nasal cannula was observed resting on top of the bed without a plastic storage bag, contrary to the facility's infection prevention policy. Staff interviews revealed that oxygen tubing and equipment should be stored in clean plastic bags when not in use, and any contaminated equipment should be replaced. The facility's policy, revised in October 2022, mandates that all medical equipment be handled and stored to minimize contamination risk, yet these practices were not followed, leading to the identified deficiencies.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Ottawa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baldwin Healthcare & Rehab Center, Llc | 13.2 mi | ★★★★★ | 11 | 0 |
| Wellsville Manor | 13.6 mi | ★★★★★ | 23 | 0 |
| Richmond Healthcare & Rehab Center | 13.7 mi | ★★★★★ | 1 | 0 |
| Brookside Retirement Community | 19.9 mi | ★★★★★ | 1 | 1 |
| Parkview Heights Nursing And Rehabilitation Center | 21.5 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.