Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Health And Rehabilitation during CMS and state inspections, most recent first.
A resident readmitted after surgery for a tibia/fibula fracture did not receive ordered enoxaparin, cefuroxime, or Vitamin D3 for several days because staff failed to obtain and implement the hospital discharge medication list. The ADON who accepted the readmission relied on a discharge summary without medication recommendations and did not contact the hospital for the missing medication list, and subsequent required reviews of admission orders by nursing leadership did not occur. Review of the MAR confirmed the medications were never started as ordered, and interviews with the physician and facility leadership showed that established admission/readmission and medication reconciliation procedures were not followed, resulting in a significant medication error and an Immediate Jeopardy finding.
A resident with vascular dementia, hypertension, major depressive disorder, and CKD stage 3, who was cognitively intact and required supervision/touching assistance for bathing, did not receive the majority of scheduled showers over a month. Facility records showed multiple missed showers with blanks or “not applicable” entries on Documentation Survey Reports, and there were no corresponding shower refusal sheets or EMR documentation of refusals. The resident reported that staff did not routinely come to get her for showers and that she had to request them, stating she did not refuse showers. A CNA shower aide and the DON confirmed that blanks indicated showers were not done, that refusals should be documented, and that residents were expected to receive showers several times per week, consistent with the facility’s bathing policy.
A Treatment Nurse failed to follow Enhanced Barrier Precautions during wound care for a resident on EBP, despite posted signage and available PPE indicating the need for a gown and gloves. The nurse performed multiple steps of wound care on an open back wound, including dressing removal, cleansing, and application of calcium alginate with silver and foam bordered dressing, while only using gloves and never donning a gown. In interviews, the nurse acknowledged that EBP requires gown and glove use for open wounds and stated she forgot due to focusing on the resident’s pain, and the DON confirmed that staff are expected to wear a gown, gloves, and additional PPE as needed for residents on EBP, consistent with the facility’s written EBP policy.
Two residents requiring Enhanced Barrier Precautions did not have proper signage or PPE carts outside their rooms, and staff failed to use gowns, change gloves, or perform hand hygiene during high-contact care activities. Facility leadership and staff were unaware of these lapses until identified by surveyors, despite facility policies requiring these infection control measures.
Surveyors observed that expired bags of spinach were left in the facility's only walk-in refrigerator, with the contents visibly spoiled and leaking onto other items. The DM admitted missing the expired items during checks, and both the Administrator and DON confirmed that food should be monitored and discarded by the use by date, as required by facility policy and food safety codes.
A resident with Alzheimer's and dementia was injured during an improper mechanical lift transfer when a CNA attempted the transfer without the required second staff member. The resident fell from the lift sling, sustaining a significant head injury. The care plan required two staff members for transfers, but this protocol was not followed, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions during foley catheter care for two residents. Observations showed that staff did not wear protective equipment or perform hand hygiene, despite clear signage and care plans requiring these measures. Interviews revealed a lack of understanding and adherence to infection control policies, with staff admitting to forgetting or being unsure of the requirements.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with lung cancer and another with heart failure, as required by policy. This delay in care planning could risk inadequate care. Staff interviews revealed confusion about responsibilities for completing these plans.
A resident with multiple health conditions did not receive her fentanyl patch as prescribed every 72 hours, due to discrepancies between the MAR and controlled drug record. The medication aide administered the patch on consecutive days without verifying the correct schedule, leading to potential therapeutic issues. Staff interviews highlighted the importance of accurate documentation and adherence to medication administration protocols.
The facility failed to maintain a medication error rate below 5%, resulting in a 19.23% error rate. Two residents received medications outside prescribed parameters, with blood pressure medications not withheld despite low diastolic readings. Medication aides were unaware of specific hold parameters, and the DON acknowledged potential system entry errors. The importance of adhering to medication administration policies was emphasized.
Two residents in an LTC facility experienced significant medication errors. One resident received losartan potassium despite a diastolic blood pressure below the hold parameter, while another received levetiracetam late and nifedipine against the hold parameter. Medication aides were unaware of the unusual hold parameters, and the DON noted potential system entry errors. The facility's policy emphasizes adherence to medication administration protocols.
The facility failed to provide meals according to dietary orders for three residents, leading to potential risks of malnutrition and choking. A resident with a potential for malnutrition received an incorrect portion size, another resident did not receive the double protein portion ordered, and a third resident was served cubed instead of chopped meat. The Dietary Manager and DON acknowledged these errors, highlighting the importance of adhering to physician orders.
The facility failed to maintain food safety standards in its kitchen, as observed during a survey. A sanitation bucket lacked proper sanitizer levels, and a dietary aide entered the kitchen without a hair net, risking cross-contamination. The Dietary Manager and Administrator expected staff to adhere to sanitation protocols to ensure a clean environment for residents.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including an LVN not wearing enhanced barrier precautions during IV medication administration, CNAs contaminating clean linens with soiled ones, and the lack of COVID-19 or flu testing for symptomatic residents. Additionally, a resident with a stage 4 pressure ulcer did not receive proper wound care, as staff were observed not wearing PPE.
A facility failed to uphold resident dignity by allowing a CNA to feed two residents simultaneously due to staffing shortages. This practice was observed despite the resident's care plan requiring one-person assistance. Interviews revealed that this was a common practice to manage staff utilization, potentially affecting the resident's quality of life and willingness to eat in the dining room.
A resident with multiple health conditions was unable to reach her call light after it fell to the floor. Despite activating the call light, a CNA turned it off without addressing the resident's needs or ensuring it was within reach. The resident expressed frustration over staff frequently turning off her call light without returning. The facility's leadership acknowledged the expectation for staff to ensure call lights are accessible and answered promptly, but the policy was not provided.
A facility failed to provide a SNF ABN to a resident discharged from skilled services before exhausting covered days, leaving them unaware of potential financial liability. The resident, with severe cognitive impairment, was receiving therapy under Medicare Part A. The MDS Coordinator admitted the oversight, highlighting the importance of notifying residents and families about possible out-of-pocket charges.
A resident reported a missing watch, but the grievance was not documented or resolved promptly. The Social Worker admitted the grievance slipped through the cracks, and the grievance form was incomplete. Interviews with staff revealed that the grievance process was not properly followed, leading to a delay in addressing the resident's concern.
A facility failed to transmit a resident's MDS discharge assessment to CMS within the required timeframe due to the responsible nurse being on PTO. The resident, who had COVID-19, was discharged to the hospital, but the assessment was submitted late, as confirmed by interviews with the MDS Coordinator and the Regional Reimbursement Nurse.
A resident with metabolic encephalopathy and mild cognitive impairment sustained a skin tear during a transfer due to an inaccurate care plan that did not reflect her current ADL status. The care plan incorrectly stated she required two staff and a Hoyer lift, while staff reported fluctuating assistance needs. The MDS Coordinator and DON admitted the care plan was not updated, leading to potential risks.
A resident with severe cognitive impairment and limited mobility was not provided with the prescribed brace for her right arm, necessary to prevent further contracture. Despite care plan instructions, the brace was repeatedly found off the resident, and staff interviews revealed confusion over responsibility for its application.
A resident with severe cognitive impairment was injured during a Hoyer lift transfer when the lift's cradle hit her above the right eye. Despite being trained, the CNAs involved failed to prevent the incident, which was observed and reported by the resident's family. The facility's policy emphasizes safe transfers, but the incident indicates a lapse in adherence to these guidelines.
A resident with multiple health issues, including paraplegia and a stage 4 pressure ulcer, did not receive proper incontinent and catheter care, increasing the risk of urinary tract infections. Staff were observed not wearing PPE and failing to follow infection control protocols, despite facility policies requiring such measures.
A resident with pneumonia receiving IV medications through a PICC line experienced a deficiency in care when an LVN failed to follow protocol by not checking the line's patency before administering a saline flush. Despite encountering resistance, the LVN did not notify a physician, contrary to facility policy. The DON confirmed the protocol breach, emphasizing the importance of proper PICC line management.
The facility failed to ensure proper labeling and storage of medications for two residents. A resident with orthostatic hypotension had hydrocortisone cream 1% on her nightstand without an order, while another resident with macular degeneration had eye drops at her bedside without an order. Both residents were assessed as unable to self-administer medications. The facility's policy did not address these storage issues, and staff interviews confirmed the lack of compliance with medication storage protocols.
The facility failed to provide timely lab services for two residents, missing several physician-ordered tests. A resident with hypothyroidism did not receive required CBC, CMP, Lipid panel, TSH, and T4 tests, while another with hypertension missed CBC, CMP, TSH, and Lipid tests. Staff interviews revealed systemic issues in lab monitoring, with the ADON and DON acknowledging lapses in oversight. The facility lacked a specific policy for lab monitoring, contributing to the deficiency.
The facility failed to follow the recipe for pureeing hamburger beef patties during a lunch meal, as the dietary staff did not have access to the recipe due to a computer issue. This could impact the nutritional value of the meal provided to residents.
Failure to Reconcile and Implement Hospital Discharge Medications After Readmission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors following a hospital readmission. The resident was readmitted after hospitalization for a left tibia and fibula fracture that required surgical intervention and had multiple diagnoses including osteopenia, anemia, atherosclerotic heart disease, dementia with severe cognitive impairment, and Type II diabetes. The hospital discharge summary and medication list directed that the resident start cefuroxime 500 mg twice daily for 5 days, enoxaparin 40 mg subcutaneously daily for 28 days beginning the day after discharge, and Vitamin D3 5000 units orally daily beginning the day after discharge. Review of the facility’s MAR for the month showed that these medications were never initiated upon readmission, and the resident missed approximately five days of all three ordered medications. The events leading to the deficiency centered on failures in the admission/readmission and medication reconciliation processes. The ADON on duty when the resident arrived by ambulance stated she did not receive a discharge medication reconciliation form and instead followed the discharge summary, which did not list medication recommendations. She acknowledged she did not contact the hospital to obtain the discharge medication list, despite facility processes that required verification of discharge medications with the accepting physician, data entry into the EMR, and ordering of new medications. The medical records technician reported that she uploads all hospital discharge records provided to her into the EMR and that the discharge medication list was not included in the packet she received. Multiple nursing staff, including RNs and ADONs, described their usual practice of reviewing discharge documents, obtaining missing medication lists from the hospital, reconciling medications with the physician, and entering orders into the EMR, but each confirmed they did not complete the readmission for this resident and therefore did not perform these steps for her. The deficiency was further supported by interviews with leadership and the attending physician. The physician stated he was notified later that the hospital discharge instructions had not been followed and confirmed that the resident had not received the ordered enoxaparin, cefuroxime, or Vitamin D3 after readmission until new orders were obtained. He indicated that he expects the admitting nurse to notify him of accurate physician orders at the time of admission or readmission. The DON and Administrator both acknowledged that the facility’s admission/readmission process requires review of admitting orders, including medications, and that the DON/ADON or designee is responsible for reviewing these orders the following day or the following Monday if the admission occurs on a weekend. The DON could not explain why this resident’s admitting orders were not reviewed per protocol. The facility’s undated Admission/Readmission policy stated that medical diagnoses and physician orders, including medication orders, should be reviewed as specified by the physician, but this did not occur for the resident, resulting in the omission of the ordered anticoagulant, antibiotic, and vitamin D therapy for several days. During observation after the error was identified, the resident was seen seated in a Geri-chair, pleasantly confused, clean, and appropriately dressed, with no signs of distress. A focused physical assessment of the left lower leg surgical site and upper body was conducted to look for signs of bleeding, bruising, warmth, redness, tenderness, or swelling that might indicate infection or DVT, and no adverse findings were identified. The surgical site was clean, dry, and intact, with one healing bruise on the left temple from a previous incident. Despite the absence of observed adverse outcomes at the time of the survey, the surveyors determined that the failure to obtain and implement the hospital discharge medication list and to reconcile and transcribe the physician’s orders constituted a significant medication error and resulted in an Immediate Jeopardy situation for the resident.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing assistance and maintain grooming and personal hygiene for a cognitively intact resident who required supervision or touching assistance with bathing. The resident, an older female with vascular dementia, hypertension, major depressive disorder, and stage 3 chronic kidney disease, was care planned for supervision as needed with bathing and was scheduled for showers on Mondays, Wednesdays, and Fridays. Documentation Survey Reports for February 2026 showed the resident was scheduled for 12 showers/baths but did not receive 7 of them, with missed showers on multiple specified dates. On some dates, the Documentation Survey Report listed scheduled bathing as “not applicable,” and on others there were blank spaces where showers were scheduled, both of which the DON and CNA A indicated meant the shower was not done. The EMR contained no shower refusal sheets for the month, and the DON confirmed there were no unuploaded refusal sheets for this resident. During interviews, the resident stated she did not remember if she had missed showers over the past two months but reported that staff did not come to get her for showers and that she had to pursue getting a shower if she wanted one. She stated she did not refuse showers and that when she did not receive her scheduled showers, she felt “yucky.” CNA A, who worked as the shower aide, reported that residents were to receive showers every other day, that a blank on the Documentation Survey Report indicated a shower was not done, and that refusals should be documented on a shower refusal sheet and in the Documentation Survey Report. The DON stated she expected residents to receive showers three times a week and that refusals occurring more than twice in one week should be documented in progress notes. Review of the facility’s bathing policy indicated that bathing is done to remove soil, dead epithelial cells, microorganisms, and body odor to promote comfort, cleanliness, circulation, and relaxation, and that aging skin can be maintained by bathing every two days or with partial bathing as needed, underscoring that the resident’s scheduled bathing was not provided as planned or documented as refused.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) protocol during wound care for Resident #2, who had an open back wound requiring treatment with calcium alginate with silver and a foam bordered dressing. On 3/3/26 at 1:32 p.m., a Treatment Nurse performed wound care in a room where EBP signage and PPE, including a red sign indicating the need for a personal care gown and gloves, were posted outside the resident’s room. The Treatment Nurse knocked, entered, assessed the resident’s pain, performed hand hygiene, and donned gloves, but did not put on a gown at any point during the wound care procedure. The nurse removed the old dressing, cleansed the wound per physician orders, applied the ordered dressings, and disposed of supplies, changing gloves and performing hand hygiene between steps, but never donned a gown despite the posted EBP requirements. During an interview later that afternoon, the Treatment Nurse stated that EBP stands for enhanced barrier precautions and acknowledged that EBP includes wearing a gown and gloves when providing care, specifically for open wounds and for urinary catheter or colostomy care. The nurse explained that she forgot to put on a gown because she was focused on the resident’s pain, and stated that she usually wears a gown and gloves when performing wound care, recognizing that EBP is important to prevent cross contamination, spread of bacteria, and for infection control. In a separate interview, the DON stated that when a resident is on EBP, staff are expected to wear a gown, gloves, and mask or face shield if needed when providing direct care, and that EBP is necessary for residents with open wounds, urinary catheters, PICC lines, and PEG tubes. The facility’s Enhanced Barrier Precautions policy indicated that EBP is an infection control intervention using targeted gown and glove use during high-contact resident care activities to reduce MDRO transmission, to be used in conjunction with standard precautions.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling catheters and other risk factors. Certified Nursing Assistants (CNAs) providing incontinent and catheter care to one resident did not perform hand hygiene or change gloves between dirty and clean tasks, and used the same gloves and wipes for multiple care activities, including handling clean briefs and linens. The CNAs also did not wear gowns as required for EBP, and there was no EBP signage or PPE cart outside the resident's room at the time of care. The CNAs acknowledged their failure to follow proper infection control procedures and stated that they were only provided gowns after informing a nurse that a surveyor would be observing care. Another resident with an indwelling catheter and EBP orders also did not have the required EBP signage or PPE cart outside her room. Staff assigned to this resident were unaware of the need to use gowns and gloves during care activities, and did not use the appropriate PPE. The charge nurse for this resident confirmed awareness of the EBP order but did not ensure the necessary signage or PPE cart was in place, only realizing the omission when questioned by the surveyor. The signage and cart were only placed outside the room after the deficiency was identified during the survey. Interviews with facility leadership, including the Director of Nursing (DON), Infection Preventionist (IP) nurse, and interim Administrator, revealed that they were not aware that the required EBP signage and PPE carts were missing for these residents. The facility's policies required hand hygiene, glove changes between dirty and clean tasks, and the use of gowns and gloves for residents on EBP during high-contact care activities. The IP nurse stated she was responsible for ensuring signage and PPE availability but was unaware of the lapses until the survey. The DON and Administrator confirmed expectations for proper infection control practices, which were not met in these instances.
Expired Food Not Removed from Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation in the facility's only walk-in refrigerator, two bags of spinach with a use by date that had already passed were found stored on the top shelf. The spinach was visibly spoiled, appearing dark green and greenish brown, wet, slimy, and had leaked onto boxes below. The Dietary Manager (DM) acknowledged responsibility for checking use by dates and removing expired items, admitting that these bags of spinach were missed. The Administrator and Director of Nursing (DON) both confirmed their expectations that food should be monitored for expiration and discarded if expired, noting that failure to do so could result in contamination or illness. A review of the facility's food storage policy and the U.S. Public Health Service Food Code confirmed the requirement for date marking and timely removal of expired, ready-to-eat, time/temperature control for safety foods. The policy and code specify that perishable foods must be consumed or discarded by the use by date to prevent spoilage and potential foodborne illness. The facility's failure to adhere to these standards was directly observed and confirmed through staff interviews and policy review.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, resulting in an incident involving a resident who was improperly transferred using a mechanical lift. The resident, an elderly female with Alzheimer's, dementia, and other conditions, was dependent on staff for transfers. On the day of the incident, a CNA attempted to transfer the resident using a mechanical lift without the required assistance of a second staff member. During the transfer, the resident's roommate, disturbed by the noise and light, pushed the Geri-chair, causing the resident to fall from the lift sling and sustain a significant head injury. The resident's care plan indicated a need for two staff members to assist with mechanical lift transfers, which was not adhered to during the incident. The resident, who was at high risk for falls and unable to stand, suffered a laceration to the scalp with exposure of the underlying skull, requiring emergency medical attention and repair with 22 staples. The facility's hydraulic lift policy did not specify the number of staff required for safe transfers, and the lift's owner's manual also lacked this information. Interviews and record reviews revealed that the CNA involved had previously been checked off on mechanical lift skills, including the requirement for a two-person assist. However, during the incident, this protocol was not followed, leading to the resident's injury. The facility's failure to ensure proper staff adherence to transfer protocols and to maintain a safe environment for residents was identified as a deficiency by surveyors.
Removal Plan
- Suspending CNA A pending investigation.
- In-servicing staff regarding KARDEX use in the EMR and Hydraulic Lift Use.
- Staff checkoffs by the DOR regarding Mechanical Lift Transfers.
- Ensuring 100% of staff in-serviced regarding mechanical lift use and KARDEX use in the EMR.
- Requiring staff to receive mechanical lift training from the DOR prior to being able to work the floor.
- Ongoing mechanical lift training until all staff had been trained/checked-off.
Infection Control Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of adherence to enhanced barrier precautions during foley catheter care for two residents. Observations revealed that CNA B and the DON did not wear the required protective equipment while providing care to a male resident with an indwelling catheter, despite clear signage indicating the need for enhanced barrier precautions. Similarly, RN A and CNA C did not follow the necessary precautions or perform hand hygiene during glove changes while caring for a female resident with a similar condition. The male resident, who was admitted with obstructive and reflux uropathy and benign prostatic hyperplasia, had a comprehensive care plan that required the use of gloves and gowns during catheter care. However, during an observation, both CNA B and the DON neglected to apply these precautions. The female resident, diagnosed with neuromuscular dysfunction of the bladder, also had a care plan mandating enhanced barrier precautions. Despite this, RN A and CNA C failed to adhere to these protocols, and CNA C admitted to forgetting to sanitize her hands during glove changes. Interviews with the staff involved revealed a lack of understanding and adherence to the infection control policies. CNA C and RN A expressed uncertainty about the requirements for enhanced barrier precautions, and both acknowledged the importance of hand hygiene, which was not performed. The DON admitted to forgetting to apply the necessary precautions due to being in a hurry. The facility's catheter care policy did not address hand hygiene or enhanced barrier precautions, contributing to the oversight.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. Resident #1, a female with multiple diagnoses including lung cancer, COPD, and diabetes, was admitted on 8/26/24. However, her baseline care plan was not completed within the required timeframe, with only an activity-related care plan initiated on 8/27/24. The comprehensive care plan was not initiated until 8/30/24, and the baseline care plan was acknowledged on 8/29/24, indicating a delay in the development of a complete care plan. Similarly, Resident #2, who was admitted on 8/30/34 with conditions such as heart failure and hypertension, also did not have a baseline care plan completed within 48 hours. The comprehensive care plan for Resident #2 was not initiated until 9/3/24, and the baseline care plan was acknowledged on 8/31/24. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for completing baseline care plans, with different staff members providing varying accounts of the process and responsibilities. The facility's policy mandates the completion and implementation of a baseline care plan within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events. However, the facility did not adhere to this policy, as evidenced by the lack of timely baseline care plans for Residents #1 and #2. This failure could potentially place newly admitted residents at risk of receiving inadequate care and services.
Failure in Medication Administration Timing
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of a fentanyl transdermal patch. The resident, a female with a history of lung cancer, neuroendocrine tumors, alcoholic cirrhosis, COPD, and diabetes, was supposed to receive a fentanyl patch every 72 hours for pain management. However, the records indicated that the patch was administered on consecutive days, 8/29/24 and 8/30/24, instead of the prescribed 72-hour interval. The discrepancy arose because the Medication Administration Record (MAR) did not match the controlled drug record, and the medication aide (MA B) did not verify the correct schedule. MA B administered the patch according to the MAR, despite noticing the inconsistency with the 72-hour order. The aide did not question the discrepancy due to a lack of nursing qualifications and the belief that the orders were frequently changing. This led to the resident receiving the medication earlier than prescribed, which could potentially affect the therapeutic benefit. Interviews with staff, including the Hospice Nurse, RN A, LVN C, and the Director of Nursing (DON), highlighted the importance of accurate documentation and adherence to the 5 rights of medication administration. The DON emphasized that any discrepancies should be reported to the charge nurse before administering medication. The facility's policy required medications to be administered by licensed personnel and documented immediately, but this protocol was not followed in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 19.23 percent error rate. This was observed in the cases of two residents. One resident was administered Centrum Silver as ordered, but their losartan potassium, a blood pressure medication, was not withheld despite a diastolic blood pressure reading of 63, which was below the ordered parameter of holding the medication for a diastolic blood pressure less than 90. Another resident received their levetiracetam and baclofen medications late, and their nifedipine, also a blood pressure medication, was not withheld despite a diastolic blood pressure reading of 84, which was also below the ordered parameter. During observations, it was noted that the medication aides were unaware of the specific hold parameters for the blood pressure medications, which were not the usual parameters they were accustomed to. The aides did not notify the charge nurse to clarify the orders with the doctor, leading to the administration of medications outside the prescribed parameters. The Director of Nursing (DON) acknowledged that the parameters might have been entered incorrectly into the system, and the medication aides likely overlooked the unusual parameters. Interviews with the medication aides and the DON revealed a lack of awareness and communication regarding the specific medication parameters. The aides admitted to administering medications late due to facility circumstances and not adhering to the prescribed hold parameters, which could have led to adverse reactions. The DON and the Administrator emphasized the importance of following the medication administration policy to ensure the effectiveness and safety of the medications administered to residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two of the five residents reviewed for medication administration. Resident #72 was administered losartan potassium, a blood pressure medication, despite having a diastolic blood pressure of 63, which was below the ordered parameter of holding the medication for a diastolic blood pressure less than 90. This error occurred on June 18, 2024, when Medication Aide L prepared and administered the medication without adhering to the specified hold parameters. Resident #73 experienced two medication administration errors. Firstly, the resident's levetiracetam, an anticonvulsant medication, was administered late. Secondly, nifedipine, another blood pressure medication, was given despite the resident having a diastolic blood pressure of 84, which was below the ordered hold parameter of less than 90. Medication Aide K, who administered these medications, was unaware of the specific hold parameters and did not notify the charge nurse for clarification. The errors were attributed to the medication aides' unfamiliarity with the unusual hold parameters and the potential incorrect entry of these parameters into the system. Interviews with the Director of Nursing (DON) and the Administrator revealed that the normal hold parameters for diastolic blood pressure were less than 60, not less than 90, indicating a possible error in the system entry. The DON and Administrator emphasized the importance of adhering to the physician's orders to prevent adverse effects and ensure the effectiveness of the medications. The facility's medication administration procedures policy highlighted the need to follow the 10 rights of medication administration, including the right time and right assessment, to maximize therapeutic effects and prevent significant medication interactions.
Failure to Provide Meals According to Dietary Orders
Penalty
Summary
The facility failed to ensure that three residents received meals prepared according to their specific dietary needs, as ordered by their physicians. Resident #54, who had a potential for malnutrition, did not have diet orders addressing her nutritional needs, and she received a single serving of pot roast instead of the one-and-a-half pieces of meat she was supposed to receive. This oversight was acknowledged by the Dietary Manager and the Director of Nursing (DON), who both stated that the correct portion was crucial to prevent weight loss. Resident #41, who was on a regular diet with double protein portions, also received an incorrect meal serving. During an observation, it was noted that she received a single serving of pot roast instead of the double portion ordered by her physician. The Assistant Director of Nursing (ADON) confirmed the error and returned the tray to the kitchen for correction. The Dietary Manager and DON both recognized the importance of following physician orders to prevent malnutrition. Resident #76, who required chopped meat due to her dietary order, was served cubed chicken parmesan instead. The ADON identified the discrepancy and returned the tray for correction. The Dietary Manager and DON acknowledged the error, emphasizing the risk of choking and weight loss if dietary orders are not followed. The facility's policies did not adequately address the specific dietary needs, such as chopped or double portions, contributing to these deficiencies.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. On one occasion, a sanitation bucket used for cleaning food preparation surfaces was found to contain a brownish clear liquid with debris and no detectable sanitizer, despite staff claims that it had been prepared correctly earlier. This failure to maintain appropriate sanitization levels could lead to the spread of bacteria, as the purpose of the sanitizer is to prevent such contamination. Additionally, a dietary aide was observed entering the kitchen without wearing a hair net, which is required to prevent cross-contamination and hair from getting into residents' food. The dietary aide explained that the hairnets available at the kitchen's entryway were inadequate for containing his hair, leading him to retrieve a hair net from inside the kitchen. The Dietary Manager and Administrator both expressed expectations that staff would maintain proper sanitation levels and wear hair nets at all times to ensure a clean and healthy environment for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a Licensed Vocational Nurse (LVN) who did not wear enhanced barrier precautions, specifically a gown, while administering intravenous medications through a PICC line for a resident diagnosed with pneumonia. This oversight occurred despite the resident's care plan indicating the need for such precautions to prevent the spread of infection. Another deficiency was observed when two Certified Nursing Assistants (CNAs) contaminated clean linens with soiled ones while providing assistance with activities of daily living (ADLs) for a resident. The CNAs placed clean linens on top of soiled ones, which they acknowledged was against infection control practices. This action could potentially lead to cross-contamination and the spread of infections among residents. Additionally, the facility did not test two residents for COVID-19 or influenza when they exhibited respiratory symptoms, despite having a history of respiratory infections. The facility's policy, aligned with CDC guidelines, required testing for symptomatic individuals, but this was not followed. Furthermore, a resident with a stage 4 pressure ulcer did not receive proper wound care, as evidenced by a family member's report and video footage showing staff not wearing personal protective equipment during care. These failures highlight significant lapses in infection control practices within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by resident rights, by allowing a CNA to feed two residents simultaneously during a lunch meal. This practice was observed during a survey, and it was noted that the CNA was feeding both residents at the same time due to insufficient staffing. The resident in question, an elderly female with severe cognitive impairment and dysphagia, required one-person assistance with eating according to her care plan. However, the CNA's actions were contrary to this plan, potentially compromising the resident's dignity and quality of life. Interviews conducted with the resident's family member, the CNA, the DON, and the Administrator revealed that feeding two residents at once was a common practice due to staffing shortages. The family member expressed concern that the resident was rushed during meals, while the CNA acknowledged the importance of giving each resident the attention they deserve. The DON and Administrator both indicated that this practice was a means of managing staff utilization, although it could negatively impact the resident's willingness to eat in the dining room. The facility's policy on resident rights emphasizes the importance of treating each resident with respect and dignity, which was not upheld in this instance.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that a resident's call light was answered timely and was within reach, which compromised the resident's ability to request assistance. The resident, an elderly female with cerebrovascular disease, anxiety disorder, flaccid hemiplegia affecting the right side, and obesity, was observed in her wheelchair with the call light on the floor, out of reach. Despite having no cognitive impairment, the resident was dependent on staff for assistance with activities of daily living, including toilet hygiene and transfers. On the day of the incident, the resident activated the call light, which fell to the ground, and was unable to retrieve it. A CNA entered the room, turned off the call light, and left without addressing the resident's needs or ensuring the call light was accessible. The resident expressed frustration over the situation, stating that staff frequently turned off her call light without returning to assist her. The CNA admitted to not realizing the call light was on the ground and acknowledged the importance of ensuring it was within reach. The Director of Nursing and the Administrator both stated that staff were expected to ensure call lights were accessible and answered promptly. However, the facility's policy on call lights was not provided upon request. This deficiency in accommodating the resident's needs and preferences was observed and documented by surveyors.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to inform a resident of changes in Medicare/Medicaid coverage and potential financial liability for services not covered. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who was discharged from skilled services before exhausting their covered days. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, a male with severe cognitive impairment, was receiving speech, occupational, and physical therapy under Medicare Part A services, which began on April 19, 2024, and ended on May 9, 2024. However, the SNF ABN, which would have informed the resident and their family of the option to continue services at their own expense, was not completed. Interviews with the MDS Coordinator and the Administrator revealed that the responsibility for issuing the SNF ABN lay with the MDS Coordinators, and the regional coordinator was tasked with monitoring and oversight. The MDS Coordinator admitted that the form was missed, acknowledging its importance in notifying residents and families about potential out-of-pocket charges. The facility's policy, effective since April 30, 2018, mandates the issuance of a SNF ABN to transfer financial liability to the beneficiary. The failure to provide this notice could result in residents being unaware of changes to their service coverage.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance reported by a resident regarding a missing watch. The resident, who had no cognitive impairment and valued her personal belongings, reported the missing watch to the Social Worker on June 6, 2024. However, the grievance was not documented or followed up on until June 20, 2024, when the state surveyor requested the grievance report. The grievance form was incomplete, lacking critical information such as the individual assigned to take action, the resolution date, and the corrective action taken. Interviews with the Social Worker, DON, and Administrator revealed that the grievance process was not properly followed. The Social Worker admitted that the grievance slipped through the cracks and was not addressed within the expected timeframe. The DON and Administrator acknowledged that grievances should be documented and resolved promptly, but in this case, the grievance was not reported to the appropriate department or followed up on, leading to a delay in addressing the resident's concern.
Delayed Transmission of MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment for a resident was electronically completed and transmitted to the CMS System within the required 14 days after completion. The resident, an elderly female with a diagnosis including COVID-19, was discharged to the hospital. However, the discharge MDS assessment was not transmitted until several days past the deadline, which was attributed to the Regional Reimbursement Nurse being on paid time off (PTO) during the period when the assessment should have been submitted. Interviews with facility staff, including the MDS Coordinator and the Regional Reimbursement Nurse, confirmed the oversight. The MDS Coordinator acknowledged the importance of timely transmission to ensure proper documentation prior to discharge. The Regional Reimbursement Nurse admitted responsibility for the delay, citing her absence as the reason for the late submission. The facility Administrator also expressed an expectation for timely completion and submission of discharge assessments, emphasizing the importance of initiating the plan of care based on these assessments.
Inaccurate Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop or implement a comprehensive person-centered care plan for a resident, which did not accurately reflect her current ADL status with transfers. The resident, a female with metabolic encephalopathy and mild cognitive impairment, was initially assessed to require setup or clean-up assistance with transfers. However, the care plan inaccurately stated that she required two staff members and a Hoyer lift for transfers, leading to inconsistencies in the care provided. The discrepancy in the care plan was highlighted by an incident where the resident sustained a skin tear during a transfer. The CNA involved in the transfer stated that the resident did not require much assistance and did not use a gait belt or Hoyer lift, contrary to the care plan. Interviews with staff revealed that the resident's level of assistance fluctuated, and the care plan was not updated to reflect these changes, leading to potential risks for the resident. The MDS Coordinator and DON acknowledged that the care plan did not accurately reflect the resident's needs and that it was overlooked. The facility's policy required ongoing discussions and updates to the care plan based on the resident's changing needs, but this was not adhered to, resulting in the deficiency.
Failure to Apply Prescribed Brace for Resident's Arm Contracture
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited mobility, leading to a deficiency in maintaining or improving the resident's range of motion. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and spinal stenosis, was observed multiple times without the prescribed brace on her right arm, which was necessary to prevent further contracture. Despite the care plan and therapy recommendations indicating the need for the brace, it was repeatedly found lying on a counter instead of being applied to the resident's arm. Interviews with staff revealed a lack of clarity and responsibility regarding who was to apply the brace. The LVN assumed the brace was on when it was not, and the Director of Rehab and DON had differing understandings of who was responsible for applying the brace. The facility's policy on immobilization devices was not followed, resulting in the resident not receiving the necessary intervention to prevent deterioration of her range of motion.
Resident Injured During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a Hoyer lift, resulting in the resident being hit above the right eye by the lift's cradle. The resident, who has severe cognitive impairment and requires assistance from two staff members for transfers, was involved in an incident where the cradle of the Hoyer lift struck her during a transfer from a chair to a bed. This incident was observed and reported by the resident's family member, who noted that the resident had been hit in the head and face several times during previous transfers. Interviews with the CNAs involved in the transfer revealed that both were trained to use the Hoyer lift and understood the importance of protecting the resident from injury. However, the incident still occurred, indicating a lapse in the execution of their training. The facility's policy on hydraulic lift usage emphasizes safe transfers, yet the incident suggests a failure to adhere to these guidelines. The DON acknowledged the issue with the Hoyer lift's loose swivel and the importance of reporting injuries for assessment, while the Administrator highlighted the interdisciplinary responsibility for ensuring CNA training on lift transfers.
Inadequate Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to a risk of urinary tract infections and decreased quality of life. The resident, an elderly male with multiple health issues including acute cystitis with hematuria, paraplegia, encephalopathy, and a stage 4 pressure ulcer, was always incontinent and had an indwelling catheter. The comprehensive care plan required incontinent care after each episode and catheter care, but observations and interviews revealed that staff did not consistently follow these protocols. Specifically, staff members were observed not wearing personal protective equipment (PPE) during care, failing to change gloves or perform hand hygiene, and not following enhanced barrier precautions. The report includes specific instances where staff did not adhere to infection control measures. A video showed a CNA not changing gloves or performing hand hygiene during incontinent care, and an LVN was observed performing catheter care without wearing gloves. Interviews with staff indicated a lack of adherence to PPE protocols, with some staff members acknowledging the importance of PPE but failing to use it during care. The Director of Nursing and the Administrator both expressed expectations for staff to wear PPE to prevent infections, highlighting a gap between policy and practice. The facility's policy on perineal care emphasized maintaining cleanliness and preventing infections, but the observed practices did not align with these standards.
Failure to Follow PICC Line Protocols
Penalty
Summary
The facility failed to ensure the safe administration of intravenous (IV) fluids for a resident, leading to a deficiency in care. The resident, a male with a diagnosis of pneumonia, was receiving IV medications through a peripherally inserted central catheter (PICC) line. The facility's licensed vocational nurse (LVN) did not follow the established protocol for checking the patency of the PICC line before administering a saline flush. During an observation, the LVN encountered resistance while attempting to flush the line but did not notify the physician as required by the facility's policy. The LVN admitted to not checking for blood return to assess the patency of the PICC line, which is a critical step in ensuring the line is functioning properly. Despite experiencing resistance during the flush, the LVN continued to use the line without consulting a physician, which could indicate an occlusion. The Director of Nursing (DON) confirmed that the protocol was not followed, as the nurse should have stopped using the line and notified the doctor upon encountering resistance. The deficiency was further highlighted by the fact that the LVN had received IV training and was deemed competent in IV skills, including the management of PICC lines. However, the LVN's actions did not align with the facility's policy, which required notifying a physician if resistance was met during a flush. The DON later confirmed that the PICC line was functioning properly and notified the doctor, but the initial failure to follow protocol posed a risk to the resident's safety.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards, as observed in the cases of two residents. Resident #3, a female with orthostatic hypotension, was found with a tube of hydrocortisone cream 1% on her nightstand, despite not having the ability to self-administer medications. The cream was observed on two separate occasions, and Resident #3 could not recall who provided it to her. Her medical records indicated she had an order for hydrocortisone cream 2.5%, not 1%, and she was assessed as unable to self-administer medications. Similarly, Resident #13, a female with macular degeneration, was observed with a bottle of equate dry eye relief on her bedside table. She stated she used the drops herself, although her records did not show an order for these eye drops, and she was also assessed as unable to self-administer medications. The presence of these medications at the bedside was confirmed by LVN T, who noted that neither resident had an order to self-administer the medications found in their rooms. Interviews with the DON and the Administrator revealed that all staff were responsible for ensuring medications were stored appropriately, and that a self-medication assessment and order were required before residents could keep medications at their bedside. The facility's policy on medication storage, revised in 2012, did not address these specific storage issues, and the DON acknowledged that routine checks were conducted to ensure compliance, although no issues had been noticed previously.
Failure to Obtain Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to ensure laboratory services were obtained to meet the needs of two residents, leading to a deficiency in providing timely and necessary lab tests. Resident #3, a female with hypothyroidism, had physician orders for several lab tests, including CBC, CMP, Lipid panel, TSH, and T4, which were not conducted in January and April 2024 as required. Similarly, Resident #22, a female with hypertension, had orders for CBC, CMP, TSH, and Lipid tests, which were not completed in October 2023, January 2024, and April 2024. These omissions were identified during a review of the residents' electronic medical records. Interviews with facility staff revealed systemic issues in the process of obtaining and monitoring lab services. The Assistant Director of Nursing (ADON) acknowledged that floor nurses were initially responsible for pulling lab results daily, while the ADON and Director of Nursing (DON) were tasked with entering orders and completing lab requisitions. However, an audit conducted in April 2024 revealed that several residents' quarterly labs were not completed, prompting the ADON to rewrite lab requisitions. Despite these efforts, the labs for Residents #3 and #22 were still missed, and the ADON admitted to not knowing how this oversight occurred. Further interviews with the DON and the Administrator highlighted a lack of effective monitoring and oversight of lab orders. The DON admitted that while an audit ensured lab orders were in place, it did not guarantee that labs were drawn. The Administrator emphasized the importance of adhering to lab schedules to ensure residents receive necessary medications. The facility's policy on physician's orders was reviewed, but it was noted that there was no specific policy or procedure regarding lab monitoring, contributing to the deficiency.
Failure to Follow Pureed Meal Recipe
Penalty
Summary
The facility failed to ensure that the meals served to residents met their nutritional needs during a lunch meal. Specifically, the facility did not follow the recipe for pureeing hamburger beef patties on the specified date. The dietary staff member responsible for preparing the pureed meal did not have access to the recipe because the computer used to print it was not working. As a result, the staff member prepared the pureed meal based on visual consistency rather than following the specific recipe instructions. This deviation from the planned menu and recipe could potentially impact the nutritional value of the meal provided to residents. Interviews with the dietary staff and management revealed that the Dietary Manager typically printed the menu and recipes for the cooks daily, but was unable to do so on the day in question due to technical issues. The Dietary Manager and the Administrator both acknowledged the importance of following the menu and recipes to ensure residents receive the correct amount of food and nutrients. The facility's Dietary Services policy, last revised in 2012, did not specifically address the preparation of pureed meals or the necessity of following pureed recipes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sulphur Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Springs Nursing & Rehab | 1.9 mi | ★★★★★ | 15 | 0 |
| Carriage House Manor | 2.1 mi | ★★★★★ | 0 | 0 |
| Sulphur Springs Health And Rehabilitation | 2.4 mi | ★★★★★ | 16 | 0 |
| Birchwood Nursing And Rehabilitation | 18.1 mi | ★★★★★ | 1 | 0 |
| Cypress Springs Wellness & Rehabilitation | 20.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rock Creek Health And Rehabilitation.
100% money-back within 48 hours.
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.